Lexington Premier Nursing & Rehab

Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to provide the residents or family group with a private space to have a monthly scheduled Resident Council meeting. Observation and resident interviews on 08/05/2025, during the Resident Council meeting, revealed the meeting's designated space to be a non-private area of the dining room accessed by nursing staff to communicate with kitchen staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment. Observations on 08/04/2025 and 08/07/2025 of three areas of the facility revealed stained and unraveled carpet.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide food and drink that was palatable and at a safe and appetizing temperature. Observation on 08/06/2025 at 8:15 AM of the breakfast test tray on the South 200 Unit revealed the food at point of service was at unappetizing temperatures.

Inspectors wroteBased on interview, record review, review of the Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety & Oversight Group's QSO-21-19-NH Memo, and review of the facility's policy, the facility failed to maintain documentation of screening, education, offering, and current Coronavirus Disease 2019 (COVID-19) vaccination status for 5 of 5 sampled staff, Registered Nurse (RN) 2, Licensed Practical Nurse (LPN) 2, State Registered Nurse Aide (SRNA) 10, SRNA11, and SRNA12.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 4 sampled residents, Resident (R) 54.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to provide documentation they notified the resident and/or the resident's representative in writing of the reason for the transfer/discharge to the hospital or of the facility's bed hold policy, including reserve bed payment. Additionally, the facility failed to notify or send a copy of the notice to the ombudsman for 3 of 4 sampled residents, Resident (R) 9, R37 and R54.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 24 sampled residents, Resident (R) 76. R76 was prescribed scheduled narcotics for pain but did not have a care plan developed for effective pain management. The facility failed to create a care plan to address the resident's chronic pain with assessment-based goals and interventions.

Inspectors wroteBased on observation, interview, review of the facility's job description, and review of the facility's policy, the facility failed to ensure nursing staff followed the standard of care for medication administration for 1 of 4 sampled residents, Resident (R) 57. Observation on 08/07/2025 revealed the North Unit Nurse Manager prepared medications for R57. She then transferred the cup of pills to Licensed Practical Nurse (LPN) 2, who administered the medications to the resident.

Inspectors wroteBased on observation, interview, review of the Food and Drug Administration's document, review of the facility's job descriptions, and review of the facility's policy, the facility failed to correctly label opened medications and dispose of expired medications and supplies to prevent resident use for 1 of 3 medication rooms and 3 of 8 medication and treatment carts. Observation of the Rehab Unit Medication Room and Treatment Cart on 08/06/2025 revealed expired medications and supplies available for resident use. Observation of North Unit Medication Cart 3 on 08/07/2025 revealed a vial of insulin with no opened date on the box or the vial and available for resident use. Observation of South Unit Medication Cart 3 on 08/07/2025 revealed an expired inhaler was on the cart and available for resident use.

Inspectors wroteBased on observation, interview, record review, review of bleach germicidal wipe instructions, review of the facility's job descriptions, review of the facility's policies, and review of the Centers for Disease Control and Prevention (CDC) document and signage related to enhanced-barrier precautions (EBP) and transmission-based precautions (TBP), the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 3 out of 24 sampled residents, Resident (R) 16, R28, and R32. 1. Observation on 08/04/2025 revealed Licensed Practical Nurse (LPN) 2 performed a blood sugar fingerstick for R28, then went to perform a fingerstick on R32. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to develop and implement care plans with individualized person-centered interventions, to include adequate supervision and monitoring for residents at risk for elopement; and for residents with a history of falls, for seven (7) of thirty-three (33) sampled residents (Residents #1, #3, #18, #22, #24, #25, and #26). 1. Resident #1 eloped from the facility on 07/27/2023 without staffs' knowledge. The resident disabled a window alarm in his/her room and climbed out the window. Resident #1 was found at a nearby convenience store approximately forty-five (45) minutes later. Resident #1 had to cross two (2) busy roads with heavy traffic to get to the convenience store. 2. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure adequate supervision and monitoring to prevent elopements for one (1), Resident #1; and falls for six (6), Residents #3, #18, #22, #24, #25 and #26, of thirty-three (33) sampled residents. The facility failed to have an effective system to ensure adequate supervision and monitoring; and failed to develop and follow care plan interventions to prevent elopement for Resident #1. The facility was notified of the IJ at 42 CFR 483.25, Quality of Care, F689, Supervision to Prevent Accidents and 42 CFR 483.21, Comprehensive Care Plans, F656, Develop and Implement on 08/11/2023, which was determined to exist on 07/27/2023. 1. [...]

Inspectors wroteBased on interview, record review, review of the facility's Plan of Correction (POC) from the 01/28/2023 Recertification Survey, and review of the facility's Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the 01/28/2023 Recertification Survey's Plan of Correction (POC), revealed the facility was previously cited at actual harm and Immediate Jeopardy (IJ). The 09/05/2023 survey had repeat deficiencies that had been cited on the 01/28/2023 survey. Review of the falls' list, dated 04/11/2023 through 08/15/2023 revealed the residents had a total of fifty-seven (57) falls, four (4) of which resulted in major injury. [...]

Inspectors wroteBased on interview, record review, review of the facility's policy, and review of the facility's Plan of Correction (PoC) for the survey completed on 01/28/2023, with a compliance date of 04/11/2023, it was determined the facility failed to have an effective system to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. The facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to effectively track adverse resident events, analyze their causes, and implement preventative action(s). The facility failed to ensure there was an effective system to regularly review and analyze and audit data, including data collected under the QAPI program; and, failed to act on available data to make improvements and maintain substantial compliance. [...]

Inspectors wroteBased on observation, interview, record review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Census and Condition of Residents (Form 672), and review of the facility's assessment, it was determined the facility failed to provide adequate staff to provide nursing and related services. The facility failed to provide adequate supervision for cognitively impaired and incontinent residents; and failed to respond to residents' requests for assistance in a timely manner. Observation revealed call lights were not answered for extended periods of time with no staff members observed in the halls to answer them. Resident interviews revealed they had to wait for extended periods of time to have call lights answered on night shift. [...]

Inspectors wroteBased on interview, record review, and review of the Medical Director's job description, it was determined the facility failed to have an effective system to ensure the Medical Director was responsible for identifying, evaluating and addressing health care issues as well as administration and governance on safety issues. Six (6) of thirty-three (33) sampled residents had falls with injuries (Residents #3, #18, #22, #24, #25, #26), and one (1) of thirty-three (33) sampled residents left the facility without staff knowledge (Resident #1). Between 06/14/2023 and 08/15/2023, six (6) cognitively impaired residents had falls. The six (6) residents had falls for a combined total of eighteen (18) times related to self-transfers and incontinence. Four (4) of the falls resulted in major injuries. [...]

Inspectors wroteBased on interview, record review, and review of the facility's job description for the Medical Director, it was determined the facility failed to ensure residents were seen personally by a physician as required per regulation for an initial comprehensive visit, and once every thirty days after admission for seven (7) out of thirty-three (33) sampled residents (Residents #1, #3, #4, #5, #18, #22, and #26)

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to follow their policy regarding advanced directives for one (1) of thirty-three (33) sampled residents (Resident #1). Upon admission to the facility, Resident #1's daughter signed his/her Advanced Directives due to his/her impaired cognition. The facility re-assessed Resident #1's cognition to be intact; however, they failed to provide Resident #1 with information about forming and/or reviewing his/her advanced directives.

Inspectors wroteBased on interview, record review, review of the facility's incident report form, and review of the facility's policy, it was determined the facility failed to ensure residents remained free from misappropriation of property for one (1) of thirty-three (33) sampled residents (Resident #6). Resident #6 reported he/she had money missing.

Inspectors wroteBased on interviews and record review it was determined the facility failed to have a system in place to communicate appropriate information to the receiving health care facility to ensure a safe and effective transition of care for one (1) of thirty-three (33) sampled residents (Resident #2) The facility transferred Resident #2 to an out of state facility on 03/23/2023 for the need of a locked dementia care unit. The facility informed the resident's Daughter that they would transfers the resident, because they could not provide sitters for 1:1 supervision (related to an elopement) unless the daughter paid for the sitters. The daughter stated she could not afford to pay for the sitters The facility failed to inform the Ombudsman of the transfer. The facility also failed to complete the Discharge Short Summary and failed to ensure the Primary Physician Summary was completed.

Inspectors wroteBased on interview, record review, review of the facility's policy, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual it was determined the facility failed to ensure completion of the Quarterly Minimum Data Set (MDS) Assessments according to the RAI manual for one (1) of thirty- three (33) sampled residents (Resident #1). The facility failed to complete a cognitive assessment for Resident #1's Quarterly MDS Assessment on 07/05/2023.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free from significant medication errors for one (1) of thirty-three (33) sampled residents (Resident #1). The facility failed to ensure Resident #1 received insulin as ordered on seven (7) occasions between 08/04/2023 and 08/13/2023.

Inspectors wroteBased on observation, interview, and record review it was determined facility the failed to secure medications in a locked storage area; and failed to ensure only authorized personnel would have access for one (1) of thirty-three (33) sampled residents (Resident #16). Observation on 08/14/2023 revealed a needleless unopened heparin lock flush was on Resident # 16's overbed table.

Inspectors wrote2. Review of Resident #23's EMR revealed the facility admitted the resident on 05/11/2021, with diagnoses including Alzheimer's Disease, Adult Failure to Thrive, and Age-Related Debility. Review of Resident #23's Quarterly Minimum Data Set (MDS) Assessment, dated 11/06/2022, revealed the facility assessed the resident to have a BIMS' score of two (2) out of fifteen (15), which indicated severe cognitive impairment. Further review revealed the facility also assessed Resident #23 as requiring limited assistance for transferring between surfaces, walking in his/her room, and toileting; and needed substantial assistance to put on footwear. Review of Resident #23's Comprehensive Care Plan, dated 11/13/2022, revealed the facility identified the resident was at risk for falls and care planned him/her for the fall risk. Per review of the Care Plan, the interventions included: [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies and investigations, it was determined the facility failed to have an effective system in place to ensure residents who exhibited wandering behaviors or were assessed at risk for elopement received adequate supervision and monitoring for one (1) of sixty-four (64) sampled residents (Resident #1). The facility admitted Resident #1 on 11/12/2022 with diagnoses of Dementia with Agitation and assessed not to be an elopement risk on admission. The facility assessed the resident to have wandering behaviors on one (1) to three (3) days during the seven (7) day look back period. Resident #1 was documented to have been wandering the hallways and attempting to go into other residents' rooms on 11/18/2022; however, there was no documented evidence the facility reassessed the resident for elopement risk. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to provide food prepared in a form designated to meet individual needs for one (1) out of sixty-four (64) sampled residents (Resident #255). Resident #255's was admitted to the facility on [DATE] from an acute care hospital where the resident had been treated for Pneumonitis due to Inhalation of Food and Vomit. During the resident's stay in the facility, staff provided the resident with thin liquids when the prescribed diet was for honey thickened liquids. The resident was sent back to the hospital, after a two (2) day stay in the facility, with a diagnosis of Aspiration Pneumonia.

Inspectors wroteBased on observation, interview, review of Lippincott's Manual of Nursing Practice (11th edition), and review of the facility's policy, it was determined residents requiring respiratory care were not provided such care consistent with professional standards of practice. Observation revealed residents had oxygen with no signage outside of their rooms to indicate oxygen use and no dating of the oxygen tubing as well as residents with no documentation of oxygen tubing change in the electronic medical record (EMR) for eleven (11) of sixty-four (64) sampled residents, Residents #3, #28, #32, #33, #36, #37, #44, #52, #57, #80, and #150.

Inspectors wroteBased on observation, interview, review of the facility's document, and review of the facility's policy, it was determined the facility failed to store food in all three (3) nourishment refrigerators in a safe and sanitary manner. Observations, during the survey, revealed the nourishment refrigerators were soiled, and the residents' food that had been brought in from outside was not labeled or dated.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to develop the baseline care plan within forty-eight (48) hours for four (4) of sixty-four (64) sampled residents (Resident #21, Resident #90, Resident #255 and Resident #348).

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to revise the care plan following a change in condition for three (3) of sixty-four (64) sampled residents, Resident #4, Resident #87, and Resident #348. The facility failed to revise Resident #4's care plan when he/she lost a significant amount of weight. The facility failed to revise Resident #87's care plan when he/she developed a respiratory infection. The facility documented the catheter care section of Resident #348's care plan as Resolved while the resident still had an indwelling urinary catheter.

Inspectors wroteBased on interview, record review, and the facility's policy, it was determined the facility failed to provide weekend Registered Nurse (RN) coverage from 08/27/2022 through 01/14/2023, for a total of fifteen (15) weekends. Review of weekend staff schedules and timecards revealed appropriate RN coverage for eight (8) consecutive hours on weekends was not ensured by the facility during that period of time.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. Observations revealed three (3) of the five (5) medication carts were observed left unlocked. In addition, one of the medication carts was observed to have medication dispenser cup three-quarters (3/4) full of pills of various shapes and sizes, without a label, indicating what the pills were or for which resident they were intended. Further observations of medication carts revealed, Gabapentin Oral Solution, which had a pharmacy sticker that noted the medication required refrigeration, which was not stored in the refrigerator; and two (2) multi-dose bottles of medication were not dated when opened.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to immediately notify the resident's representative of an accident involving the resident which resulted in injury for one (1) of sixty-four (64) sampled residents (Resident #23). On 12/26/2021 at 6:05 PM, Resident #23 experienced a fall in his/her room, sustaining a fracture to his/her right hand and a laceration to his/her forehead, requiring transfer to the hospital. However, the facility failed to notify the resident's responsible party of the fall, injuries, and transfer to the hospital, until 8:41 PM, which was after Resident #23 had already been sent to the hospital.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to submit the initial admission Assessment within the required fourteen (14) day period for one (1) of sixty-four (64) sampled residents (Resident #20). The facility admitted Resident #20 on 07/08/2022; however, the facility did not submit the resident's Minimum Data Set (MDS) Assessment within the required timeframe. The facility submitted Resident #20's admission Assessment on 07/28/2022, twenty (20) days after his/her admission.

Inspectors wroteBased on observation, interview, record review, review of a Kentucky Board of Nursing (KBN) Scope of Nursing Comparison Chart, review of an American Nurses Association (ANA) Issue Brief, and review of the facility's policy, it was determined the facility failed to ensure residents received care according to professional standards of care and the comprehensive care plan for three (3) of sixty-four (64) sampled residents (Residents #57, #252, and #255). The facility admitted Resident #5, on 10/04/2019, with a diagnosis of Cellulitis of Bilateral Lower Limbs. The facility failed to provide care according to the Physician's recommendations for lymphedema and bilateral lower extremity wound care. The facility admitted Resident #255, on 08/26/2022, with a diagnosis of Seizures. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's policies, review of the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to ensure four (4) of sixty-four (64) sampled residents (Resident #21, #90, #150, and #348), who had an indwelling urinary catheter, received treatment and services in accordance with accepted standards of practice intended to prevent urinary tract infections (UTI). Observations of Resident #21, Resident #90, Resident #150 and Resident #348 revealed the residents had indwelling urinary catheters that were either resting on the floor, or on wheels of the bed, were unanchored, or did not have a dignity bag cover.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain acceptable parameters of nutritional status, including usual body weight for one (1) of sixty-four (64) sampled residents (Resident #4). Resident #4 had a severe weight loss of twenty-eight percent (28%) from 08/01/2022 to 01/02/2023.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to care for the resident's feeding tube to prevent complications of enteral feedings by not dating the feedings when hung and by not performing site care as ordered for one (1) of sixty-four (64) sampled residents, Resident #71.

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to provide timely Dialysis management for one (1) of sixty-four (64) sampled residents (Resident #198). The facility admitted Resident #198 on 07/22/2022 and he/she required Dialysis Care. The facility, however, failed to ensure arrangements were made to assist the resident with Dialysis Care until 07/26/2022, when the resident's spouse alerted the facility, the resident was discharged from the hospital on Hemodialysis. Additionally, the facility failed to ensure documentation of the resident's visits to his/her Dialysis provider was kept in his/her medical records, as per the facility's policy.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to provide routine medications for two (2) of sixty-four (64) sampled residents (Residents #252 and #255). The facility failed to ensure Resident #252 received his/her prescribed seizure and pain medications on the evening of 06/29/2022 and the morning of 06/30/2022, placing the resident at risk for seizures. Interview revealed the Pharmacy had not been able to fill the order for Resident #252's seizure and pain medications and deliver the medications to the facility. The facility failed to ensure Resident #255 received his/her prescribed seizure medication on 08/27/2022 and 08/28/2022, because the Pharmacy had not been able to fill the order and deliver the medication to the facility. Therefore, Resident #255 experienced a seizure on 08/28/2022 at 2:40 AM.

Inspectors wroteBased on observation, interview, record review and review of facility Policy, it was determined the facility failed to ensure a resident who is fed by enteral means receives appropriate services to prevent complications for two (2) of nine (9) sampled residents. (Residents #87 and #300). Observation on the Rehabilitation Unit during initial tour on 12/17/19, and again on 12/18/19, revealed the tube feeding bottle/bags that were hanging for Residents #87 and #300 were not properly labeled as to Resident Identification, type of formula, date and time formula was prepared, rate of administration, and nurse's initials who hung the formula.

Inspectors wroteBased on observation, interview, and review of the facility's Policy, it was determined the facility failed to ensure drugs and biological were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration dated when acceptable. Observation of the Rehab Medication Cart, on 12/20/19, revealed two (2) insulin pens in the medication cart: one (1) Lantus Solostar Insulin Pen and one (1) NovoLog Insulin Flex Pen, both of which were unopened and stored in a bag that stated refrigerate until opened. There was no date on the Insulins to indicate when the medication was removed from the refrigerator, and therefore the date of expiration could not be determined. [...]