Lexington Manor Senior Care, LLC

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a smoking care plan for one (1) of 17 care plans reviewed. Resident #44 Findings include: A review of a facility policy titled, Comprehensive Care Plans, reviewed 10/23 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident An observation on 10/16/24 at 10:00 AM, revealed Resident #44 smoking with the supervision of Housekeeper #1. During the observation it was revealed that Resident #44 was observed to not be wearing a smoking vest while he was smoking a lit cigarette. A review of the care plan titled, Resident #44 is at risk for injuries related to smoking, revealed, Interventions: Resident #44 will require a smoking apron due to falling asleep while smoking initiated 5/28/24. In an interview with the Minimum Data Set (MDS) Coordinator on 10/16/24 at 10:53 AM, it was revealed after review of Resident #44's smoking care plan that staff were not following the care plan to wear a smoking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review, the facility failed to promote an environment as free of accident hazards as possible, when the facility failed to provide a resident a smoking protection assistive device to prevent accidents for one (1) of three (3) residents reviewed for accidents and hazards.(Resident #44) Findings include: A review of the facility policy titled, Smoking/Tobacco Use Policy, last review 2024 revealed, Procedure: 5.) Smoking aprons will be provided for residents who are evaluated to need them by the smoking safety assessment. Wearing of the apron will be assisted by staff during smoking times for those residents who require them . An observation of Resident #44 on 10/15/24 at 12:52 PM, revealed small cigarette burn holes on the blanket covering his legs. A record review of a Smoking Safety Screen for Resident #44 dated 5/28/24, revealed the resident needed adaptive equipment during smoking with a smoking apron and supervision. Notes on safety from Interdisciplinary team: Staff noted that Resident #44 fell asleep…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility failed to accurately complete an Annual Minimum Data Set (MDS) for a resident that had a serious mental illness for one (1) of 17 MDS reviews. Resident #2 Findings Include: The facility provided a statement on letterhead dated 10/16/24, It is the practice of this facility, Proper Name, to document data for the MDS 3.0 according to the instructions per the RAI (Resident Assessment Instrument) Manual. Record review of Resident #2's Preadmission Screening and Resident Review (PASRR) Summary of Findings Report dated 3/23/23 revealed under, Mental Health: . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR with the primary diagnosis of Schizophrenia. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #2 on 4/6/23 with a medical diagnosis of Schizophrenia. Record review of Resident #2's Annual MDS with an Assessment Reference Date (ARD) of 3/14/24 revealed under section A, Is the resident currently considered by the state level II PASRR process to have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review and facility policy review the facility failed to provide nail care for a resident dependent on staff for Activities of Daily Living (ADL's) as evidenced by brown substance under the resident's nails for one (1) of five (5) residents reviewed for ADL's. Resident # 48 Findings include: A review of the policy titled, Care of Fingernails for the Certified Nursing Assistant, dated 5/2019, revealed Policy: It is the purpose of this procedure to provide appropriate care according to current standards of practice. Care of fingernails will be provided by the Certified Nursing Assistant . An observation of Resident #48 on 8/08/23 at 1:00 PM, revealed the resident's fingernails to be approximately 1/4 inch long with an unknown dark brown substance under the nail beds. During an observation and interview of Resident #48's nails on 8/09/23 at 8:30 AM, with Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA)#1 revealed both CNA #1 and LPN #1 confirmed Resident #48's nails were approximately 1/4 inch long and had a brown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review the facility failed to implement an Activities of Daily Living (ADL) care plan for one (1) of 20 care plans reviewed. Resident #48 Findings include: A review of the facility policy titled, Comprehensive Care Plans, revised 2/2017, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. #4 The Comprehensive Care Plan will describe at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . An observation of Resident #48 on 8/08/23 at 1:00 PM, revealed the resident's fingernails to be approximately 1/4 inch long with an unknown dark brown substance under nail beds. A review of the care plan for Resident #48,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review and facility policy review the facility failed to maintain an environment that is free from accident hazards as is possible when an office door behind the nursing desk was left open and unsecured with a gallon bottle of Hibiclens (chlorhexidine gluconate), a small bottle of Hydrogen peroxide, syringes with needles intact, two (2) boxes of butterfly needles, vacutainer's, and a bottle of covid testing solution sitting on a shelf visible from the doorway for one (1) of three (3) days of survey. Findings include: A review of the facility policy titled, Storage of Medication, revealed, Policy: Medications and biological's are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. The medication is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedures: B.) Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access . Record review of a typed document on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview, record review and facility policy review, the facility failed to store narcotics in the permanently affixed compartment in the refrigerator and left an office door behind the nursing desk open and unsecured with a gallon bottle of Hibiclens (chlorhexidine gluconate), a small bottle of Hydrogen peroxide and a bottle of covid testing solution sitting on a shelf one (1) of three (3) days of survey. Findings Include: A review of the facility policy titled, Storage of Medication, revealed, Policy: Medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. The medication is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedures: B.) Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access. A review of the facility policy titled, Medication Storage in the Facility,revealed . The scheduled two-five medications and other medications subject to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and facility policy review, the facility failed to prevent the potential of a food borne illness as evidenced by food open and used after the expiration date and food stored with an open lid and past the use by date on one (1) of three (3) kitchen tours. Findings include: The facility policy titled, Storage of Refrigerated Food with a revised date of 10/17 revealed POLICY: The facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. PROCEDURE: . 4. Food taken out of original containers is put in a clean sanitized container with a tight-fitting lid. No food is left uncovered. 5. All opened foods are labeled with common name of food, date stored and use-by date. An observation on 11/29/21 at 10:20 AM, of the kitchen revealed in the walk-in refrigerator a half gallon container of buttermilk that was 3/4 (three-fourths) empty. The container had an expiration date of 11/4/21 and an opened date of 11/17/21. An interview on 11/29/21 at 10:20 AM, with Dietary Staff #3 confirmed that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide nail care for a resident who was dependent for her Activities of Daily Living (ADLs) as evidenced by a brown substance on top of and underneath all fingernails for one (1) of eight (8) residents observed for ADL care. Resident #26 Findings include: Review of the facilities policy titled, Shower-Tub Bath Policy dated 04/2017 revealed Policy It is the policy of this facility to promote cleanliness and comfort, to relax the resident, to stimulate circulation, and to observe the condition of the resident's skin . Procedure . 8. Wash hands properly. Review of the facilities policy titled, Care of Fingernails for the Certified Nursing Assistant dated 5/2019 revealed Policy: It is the purpose of this procedure to provide appropriate care according to current standards of practice. Care of fingernails will be provided by the Certified Nursing Assistant for all no-Diabetic residents .Procedure: . 4.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure the proper labeling of oxygen tubing and humidifier bottles and failed to place signage on resident doors indicating oxygen was in use for 4 (four) of 6 (six) residents receiving oxygen therapy. Residents #2, #26, #28 and #36. Findings include: Review of the facility policy Oxygen Concentrator reviewed 2021 revealed, . Policy Explanation and Compliance Guidelines: .h. Place an oxygen warning sign on the resident's door. Review of the facility's policy titled, Nebulizer and Oxygen Tubing Storage Policy with a review date of 2021 revealed, POLICY It is the policy of this facility to decrease the risk of potential and/or direct exposure to infection diseases, air contaminants, and bacterial exposure. We will provide our residents with the proper storage and cleaning of respiratory equipment. PROCEDURE The facility will replace all respiratory tubing's weekly. These tubing's will be dated and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, facility policy review, the facility failed to prevent the possible spread of infection by failure to clean and disinfect multi-use equipment between resident use for one (1) of four (4) days of survey. Findings include: Review of facility policy titled, Policy for Cleaning and Disinfection of Resident-Care Equipment, dated 3/31/21, revealed, Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control) recommendations in order to break the chain of infection .Policy Explanation and Guidelines, 3b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use of another resident. An observation, on 11/29/21 at 12:15 PM, revealed CNA #5, entered and exited the rooms of Resident #31, Resident #14, and Resident #48 using a [NAME] V 3 Automated Vital Sign System to check…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.