Retreat at Wellmore of Lexington

Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to ensure Resident (R)43 was free from significant medication error. Specifically, the facility failed to ensure that R43 received the correct medication order for Bupropion/Wellbutrin, which led to the resident being hospitalized . On 05/21/25 at 1:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 03/04/25. The IJ was related to 42 CFR 483.25 - Pharmacy Services. On 05/22/25 the facility provided an acceptable IJ Removal Plan. On 05/22/25 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 03/13/25. [...]

Inspectors wroteBased on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the refrigerator and dry storage were labeled and discarded after the manufacturer's expiration date. Findings Include: Review of the facility's policy titled, Food Receiving and Storage, with a revised date of November 2022, reveals, Food shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated. Such foods are rotated using a first in-first out system. Refrigerated/Frozen Storage: 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During an initial tour observation on 01/29/24 at 12:24PM, in the walk-in refrigerator and dry storage area revealed: 1. [...]

Inspectors wroteBased on review of the facility policy, observations, interviews, and record review, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to ensure 2 of 2 residents (R) 34 and R195's, continuous positive airway pressure (CPAP), were properly cleaned and stored after each use. This failure has the potential to cause respiratory and other communicable infections/complications. Findings Include: Review of the facility policy titled, CPAP/BiPAP Support, with a revised date of March 2015, states, 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. [...]

Inspectors wroteBased on review of the facility policy, observations, interviews, and manufacturer package inserts, the facility failed to maintain clean medication carts for 2 of 7 med carts and failed to prevent expired and/or improper storage of medications in 2 of 4 med rooms.

Inspectors wroteBased on review of the facility policy, observation, and interview, the facility failed to establish and maintain an infection prevention and control program to prevent the development and transmission of communicable disease and infections related to influenza for one of one, Resident (R)1.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure foods stored in the kitchen were labeled, dated, and not expired. These failures had the potential to increase the prevalence and spread of foodborne illness and infection to all facility residents.

Inspectors wroteBased on observations, record review, staff interviews, review of the manufacturer's guidelines for medication use, and review of the facility's policy and procedures, the facility failed to ensure that three of five residents (Resident (R) R30, R41, and R42) reviewed for unnecessary medication use did not receive psychoactive medications without an appropriate assessment and indication for use, monitoring of adverse effects, attempting gradual dose reductions when appropriate, reducing or discontinuing as needed psychotropics past the 14 day criteria, identifying and routinely monitoring specific target behaviors, and developing and implementing resident specific non-pharmacological interventions. This deficient practice had the potential for serious harm and/or death for all residents who reside in the facility.

Inspectors wroteBased on record reviews, interviews and review of the facility policy titled, Advance Directives, the facility failed to ensure Resident (R)19 and R42 were afforded the right to formulate an advance directive for 2 of 4 residents reviewed for Advance Directives. Findings Include: The facility admitted R19 with diagnoses including, but not limited to, bipolar disorder, schizoaffective disorder, anxiety and legal blindness. Review on [DATE] at 1:22 PM of the medical record for R19 revealed no documentation to ensure R19 was afforded the right to formulate an Advance Directive. Further review on [DATE] at 1:25 PM of the medical record for R19 revealed no assessments and signatures of 2 physician's indicating that R19 was not able to make her own healthcare decisions. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for one of two residents (Resident (R) R42) reviewed for environment. Specifically, R42 had food crumbs, paper trash, and other particles on the floor. This had the potential to affect all 47 residents residing in the facility. Findings Include: During initial tour of the facility on 01/31/22 at 12:43 PM, observation of food crumbs and paper trash were noted lying on the floor in R42's room. Observation on 02/01/22 at 8:54 AM , food crumbs and paper trash were observed on the floor in R42's room located in the same place as observed on the previous day. Observation on 02/02/22 at 8:59 AM, food crumbs and paper trash were observed on the floor in R42's room located in the same place as observed on the previous dates of 01/31/22 and 02/01/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Residents (R) R30 and R42), who were given mental health diagnoses and were not provided a Pre-admission Screening and Resident Review (PASARR) level 2 evaluation to determine the need for individualized mental health treatment and support services. Specifically, R30 was admitted with diagnoses of depression and psychotic disorder and received antipsychotic medication with no PASARR level 2 referred. R42 was admitted with a diagnosis of dementia and was later given a diagnosis of schizophrenia disorder and was prescribed an antipsychotic medication with no PASARR level 2 referred. This failure placed the residents at risk for unmet care needs, unnecessary medication/s, and at risk for not receiving appropriate mental health treatment and support/services needed. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement the comprehensive care plan interventions for two residents (Resident (R) 30 and 41) of five reviewed for psychotropic medication care plan/s. These failures had the potential to affect all residents prescribed psychotropic medications with target behaviors by increasing the potential for harm due to the facility failing to implement nonpharmacological methods that were identified on the care plan with the usage of unnecessary medications.

Inspectors wroteBased on observations, record review, interview and review of the facility's policy titled, Wound Care, and Handwashing/Hand Hygiene, the facility failed to ensure proper wound care for Resident (R)1 for 1 of 3 residents reviewed for Pressure Ulcers. Findings Include: The facility admitted R1 with diagnoses including but not limited to; pressure ulcer of left and right hip, repeated falls, difficulty walking and lack of coordination. Review on 2/2/22 at 12:05 PM of the medical record for R1 revealed a physician's order for wound care. The order reads: Clean the left and right buttocks and perineum with wound cleanser and pat dry. Apply collagen powder and calcium alginate to the wound bed and cover with a dry dressing and secure with tape. An observation on 2/2/22 at 12:10 PM of wound care for R1 went as follows: [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure there was sufficient nursing staff available to respond to call lights and assist residents as needed for five of the 12 residents (Residents (R) R32, R10, R22, R29, R39) attending the Resident group and one of two residents reviewed for environment (R32). This failure has the potential to affect all residents who resided in the facility. The census was 43.

Inspectors wroteBased on observation and interview, the facility failed to respond to Resident (R)41 during a hallucination episode. Findings Include: An observation on 2/2/22 at 11:09 AM revealed R41 in the dining area having a hallucination episode for 20 minutes with little to no staff intervention or redirection attempts. Certified Nursing Assistant (CNA)1 was observed during this time period on their phone in close proximity to the resident. Further observation revealed Physical Therapist (PT) 2 redirect the resident and assist them to the therapy gym. An interview on 2/2/22 at 11:37 AM with CNA1 revealed that he heard the resident yelling, but didn't think to help with an intervention because he thought the therapy staff had it covered. Further interview confirmed that CNA1 was on the phone looking through messages during the time of R41's hallucination episode. [...]

Inspectors wroteBased on observations, interviews and review of the facility policy titled, Administering Medications, the facility failed to ensure medications were not touched for Resident (R)145 with bare hands during administration of medications on the 200 Hall for 4 medications out of 25 opportunities for error. The medication error rate was 16 percent. Findings Include: An observation on 2/1/22 at approximately 8:00 AM of medication administration for R145 revealed Licensed Practical Nurse (LPN)1 administering medications to R145. The LPN had 4 pills in a medicine cup and went to R145's room. She sat the cup of medications on a 3 drawer compartment outside R145's room door used for personal protective equipment. The LPN accidentally knocked over the cup of medications and picked them up one by one using her bare hands. [...]

Inspectors wroteBased on observations, interviews and review of the facility policy titled, Storage of Medications, the facility failed to ensure expired medications were removed from the 200 North Hall medication cart and not stored with medications for resident use on 1 of 4 medication carts observed . The facility further failed to ensure medication carts were locked on on the 100 North Hall and on the 200 South Hall for 2 of 4 medication carts observed. The facility additionally failed to ensure expired mediations were removed from the refrigerator in the 200 South Hall medication room for 1 of 4 medication rooms reviewed. Findings Include: An observation on 2/1/22 at 3:00 PM of the 200 North Hall medication cart revealed the medication, Oxycodone 1 tablet of 5 milligrams expired on 1/20/22. [...]

Inspectors wroteBased on observations, interviews and review of the facility policy titled, Administering Medications, the facility failed to ensure medications were not touched for Resident (R)145 with bare hands during administration of medications on the 200 Hall for 4 medications out of 25 opportunities for error. Findings Include: An observation on 2/1/22 at approximately 8:00 AM of medication administration for R145 revealed Licensed Practical Nurse (LPN)1 administering medications to R145. The LPN had 4 pills in a medicine cup and went to R145's room. She sat the cup of medications on a 3 drawer compartment outside R145's room door used for personal protective equipment. The LPN accidentally knocked over the cup of medications and picked them up one by one using her bare hands. [...]