Lexington Post Acute

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when a medication was found unattended and unsecured in 1 of 5 (Resident #40) resident occupied rooms observed during medication administration.

Inspectors wroteBased on policy review, Quarterly Payroll Based Journal (PBJ) review, facility staffing information review, and interview, the facility failed to submit accurate staffing data for Quarter 4 for PBJ 2025 (July 1, 2025- September 30, 2025) reviewed for staffing data.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection during incontinence care, wound care, and medication administration for 3 of 7 (Resident #3, #13, and #92) sampled residents reviewed.

Inspectors wroteBased on policy review, record review, and interview the facility failed to provide information to the residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive for 11 of 24 (Resident #5, #11, #15, #29, #31, #41, #45, #52, #53, #58 and #60) residents reviewed for Advance Directives.

Inspectors wroteBased on policy review, observation, dish machine log, emergency menu, and interview, the facility failed to ensure that food was stored, handled, prepared, and served under sanitary conditions. The facility failed to recognize the low temperature dishwasher log had low temperatures for the wash cycle and when the emergency menu food items were not in stock. The facility had a census of 68 with 68 of those residents receiving a tray from the kitchen.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 1 resident (Resident #5) reviewed for self-administration of medication.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to report an allegation of sexual abuse to all appropriate local and state agencies for 1 of 1 (Resident #57) sampled residents reviewed for abuse.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to thoroughly investigate allegations of sexual abuse for 1 of 1 (Resident #57) sampled resident reviewed for abuse.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to showering for 2 of 2 sampled residents (Resident #41 and #45) reviewed for ADLs.

Inspectors wroteBased on policy review, medical record review, observation and interview, the facility failed to ensure infection control practices were followed during medication administration when 1 of 3 nurses Registered Nurse (RN) B failed to wear PPE (personal protective equipment) during the administration of medication by way of peg tube and when 1 of 1 Certified Nursing Assistant (CNA) C failed to perform hand hygiene during foley catheter care.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure a Registered Dietician (RD) or Qualified Nutritional Professional was employed to provide oversight of the kitchen sanitation, kitchen staff competencies, residents' prescribed diets, and meals served in a timely manner.

Inspectors wroteBased on facility policy review, document review, observation, and interview, the facility failed to provide sufficient staff with competencies and skill sets to carry out the functions of the food and nutrition services for 12 of 17 staff members (Dietary Aide A, B, C, D, E, F, Certified Nursing Assistant (CNA) G, Housekeeper H and I, Housekeeper/Laundry Supervisor, Director of Nursing (DON) and Administrator) working in the kitchen. The facility had a census of 78, with 76 of those residents receiving a meal tray from the kitchen.

Inspectors wroteBased on policy review, observation, kitchen sanitation logs, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions and when for 3 of 6 (Certified Dietary Manager (CDM) J from another facility, Dietary [NAME] O, and Dietary [NAME] V) dietary staff were observed. The dietary staff failed to cover facial hair, the kitchen floor was dirty with pieces of paper scattered on the floor, and cook ware had sticky black carbon build-up. The facility failed to take dish washer temperatures and test the sanitizing solution level of the low temperature dishwasher three times a day. The convection oven had dried food particles inside with thick brown sticky substance buildup, the metal storage racks were rusty with peeled metal and dust buildup. The facility had a census of 78 with 76 of those residents receiving a tray from the kitchen.

Inspectors wroteBased on policy review, record review, observation, and interview, the facility failed to provide a nourishing and well-balanced diet that meets each resident's daily nutritional and dietary needs for 3 of 5 (Residents #2, #5 and #16) residents reviewed for nutrition. The facility had a census of 78, with 76 of those residents receiving a meal tray from the kitchen.

Inspectors wroteBased on policy review, Timeanddateweather.com review, medical record review, observation, and interview, the facility failed to ensure a safe, secure environment for a vulnerable cognitive impaired resident for 1 of 3 (Resident #60) sampled residents reviewed for elopement. The facility's failure to ensure a safe, secure environment resulted in Immediate Jeopardy when on 8/27/2023, Resident #60 exited the facility through an unsecured door, unsupervised. Resident #60 was brought back to the facility by a unknown civilian who stated Resident #60 was found on a busy 4 lane highway, in a self-propelled wheelchair at a [Named Bank] approximately 0.19 of a mile from the facility. The temperature was 91 degrees. Resident #60 was last seen in the facility on 8/27/2023 at approximately 4:20 PM, and was brought back to the facility between approximately 4:36PM and 4:38 PM. [...]

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 5 of 13 staff members (Certified Nursing Assistant (CNA) #1, #2, #4, #5, and #6) failed to use courtesy titles to address Resident #15, #17, #20, #26, #31, #36, #39, #63, #64, #68, and #232, and 2 of 13 (CNAs #1, and #2) stood over Resident #58 and Resident #20 while assisting them to eat lunch.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure proper infection control practices when 5 of 13 (Certified Nursing Assistants (CNA #1, #3, #4, #5, and the Staffing Coordinator) staff members failed to perform hand hygiene during meal pass, placed dirty trays on the cart with clean trays, transported a tray with uncovered food items down the hall, when an enteral pump [machine used to deliver nutrition through a gastrostomy tube] and pole was observed dirty, and when toilet plungers, urinals, and wash basin were stored uncovered.

Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to provide information regarding a resident's right to formulate an advanced directive for 5 of 24 sampled residents (Resident #7, #37, #44, #53, and #58) reviewed for advance directives.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to include the resident and/or family member in the Interdisciplinary Team (IDT) Care Plan meeting for 4 of 24 sampled residents (Resident #7, #44, #58 and #69) reviewed for Care Plan Meetings.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored when a medication was left in a resident's room for 1 of 24 (Resident #54) sampled residents.