Lexington Medical Lodge

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services .1. The facility failed to seal lids securely on containers in the refrigerator area2. The facility failed to seal bags securely in the walk-in freezer.3. The facility failed to ensure that [NAME] A washed their hands after removing gloves, between tasks and before returning to food preparation tasks putting on new gloves. [SH1.1]These deficient practices could affect residents who received meals or snacks from the kitchen and place them at risk for cross contamination and other food-borne illnesses. Findings Included:During an observation and interview on 6/21/26 at 9:02 AM [NAME] A stated the Dietary Manager was not at the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #71) of eight residents reviewed for ADL care. The facility failed to provide Resident #71 with timely incontinence care on 06/21/26. This failure could place residents at risk for a skin breakdown and infection. Record review of Resident #71's quarterly MDS assessment, dated 05/30/26, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 08, indicating his mild cognitive status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #103) reviewed for feeding tube care. The facility did not ensure Resident #103 received water flushes and medication through the feeding tube by gravity flow in accordance with professional standards of practice. LVN B flushed the tube feeding and gave medication by using the plunger to push the mixture instead of by gravity flow. This failure could place residents at risk for aspiration pneumonia, abdominal discomfort, vomiting, and/or metabolic abnormalities.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning, are provided such care, consistent with professional standards of practice, for two of seven residents (Resident #82 and Resident #114) reviewed for quality of care. The facility failed to ensure that Resident #82 and Resident #114's oxygen nasal cannula tubing (a small, lightweight tubing with 2 soft prongs that sit just inside the nostrils to deliver extra oxygen) were bagged in a plastic bag. This failure could place residents receiving respiratory therapy at risk of health-associated infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident#106) of six residents reviewed for pharmacy services. The facility failed to ensure that Resident #106 swallowed his medication before leaving the resident room. This failure could place the residents at risk of medication error, reduced therapeutic effectiveness, unsafe administration, and potential adverse outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly label and store all drugs and biological in accordance with currently accepted professional principles for medications for 1 of 4 medication carts, (400-hall nurse cart) reviewed for pharmacy services. The facility failed to ensure Residents #5, #37, #48, and #117's Insulin Lispro was discarded after the opening date of [DATE] of 28 days in accordance with professional standards of practice from the 400-hall nurse cart. These failures could place the residents at risk of reduced therapeutic effectiveness, unsafe administration, and potential adverse outcomes due to improper storage of medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for three of four residents (Resident #1, Resident #2, and Resident #5) reviewed for catheter and incontinence care. 1. The facility failed to ensure CNA B provided appropriate perineal care for Resident #1 when he failed to clean the resident's penis, scrotum, and pubic area on 10/07/25. 2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 6 Residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) observed for infection control. 1. The facility failed to ensure CNA B performed hand hygiene during incontinence care to Resident #1 and failed to perform hand hygiene prior to leaving the resident's room on 10/07/25. 2. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 28 (Residents #85 and Resident #125) residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #85 and Resident #125's rooms were in a position that was accessible to the residents on 04/27/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 11 (Resident #10 and Resident #77) residents reviewed for Respiratory Care. The facility failed to ensure Resident #10's nasal cannula (flexible tube used to deliver oxygen to the nose through two prong) was stored in a bag when not in use on 04/27/2025. The facility failed to ensure Resident #77's nebulizer face mask was stored in a bag when not in use on 04/27/2025. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, Resident#3) of 3 residents reviewed for ADL's. The facility failed to ensure. 1-Resident #1 had her facial hair shaved. 2- Resident#3 had her fingernails trimmed and cleaned. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, administering of drugs and biologicals, to meet the needs of each resident for 1 of 1 medication carts (nurses cart Hall 100) reviewed for pharmacy services. The Nurses Cart Hall 100 contained a blister pack for Resident #4 that was broken. This failure could place residents at risk of not having the medication available due to possible drug diversion, diminished effectiveness, and not receiving the therapeutic benefits of the medications. Findings Include: Observation and record review on 03/12/25 at 10:14 AM of nurses' cart Hall 100, with RN C revealed: [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (Resident #2) reviewed for documentation of wound care dressing changes. The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident # 2 on 02/09/25, 02/13/25, 03/01/25, 03/02/25 and 03/09/25. These failures placed residents at risk for missed treatments and care which could result in the wound deterioration, and development of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to treat residents with respect and dignity for 1 of three (Resident #1) residents reviewed for dignity in that: Facility staff stood over Resident #1 while assisting the resident with her meal in the dining area. This failure could affect residents who require assistance with activities of daily living and placed them at risk for psychosocial harm due to a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #74) of 8 residents reviewed for comprehensive care plans. The facility failed to create and implement a care plan that reflected the Resident's preference to speak Spanish. This failure could put the Resident at risk of not being able to communicate effectively with staff, which could result in isolation, reduced psychosocial well-being, and of not getting her needs met in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #55) of two residents reviewed for catheter care. 1. The Facility failed to ensure Resident #55's foley catheter was secured prior to transferring Resident #55 from the bed to his wheelchair. 2. The facility failed to ensure CNA B and CNA C maintained the foley catheter drainage bag below Resident #55's bladder during a mechanical lift transfer. This failure placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents observed during a transfer. CNA A failed to use a gait belt when transferring Resident #1 from wheelchair to toilet back to wheelchair. This failure could place residents at risk for discomfort, pain and or injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infection to the extent possible for one (Resident#1) of five residents reviewed for incontinent care. The facility failed to ensure Resident #1 was assisted with incontinence care and toileting in a timely manner. This failure could place residents at risk of a diminished quality of life by not receiving care and services to meet their toileting needs.