Lexington Nursing Home, Inc.

Based on record review and interview, the facility failed to ensure the care plan was revised related to wound care for 1 (#19) of 12 sampled residents reviewed for care plan revision. The DON identified 39 residents resided in the facility. Findings:An undated face sheet showed Res #19 admitted to the facility with diagnoses which included heart disease, muscle wasting and atrophy, and muscle weakness.A progress note, dated 04/20/26, showed Res #19 had an open area to the lateral side of their left foot. The note showed new physician orders for wound care and to wear heel protection boot on the left foot.The care plan was not revised to include the new open area or the heel protector boot for Resident #19.On 04/30/26 at 12:59 at p.m., LPN #1 stated the new wound, and the heel protector should have been care planned.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure proper infection control for 1 (#2) of 1 sampled resident reviewed for catheter care.The DON identified 39 residents resided in the facility. The facility matrix identified two residents had catheters.On 04/27/2026 at 8:06 a.m., CNA #1 and CNA #2 were observed donning personal protective equipment which included gowns and gloves in preparation to assist Res #2 out of bed. CNA #1 emptied the catheter into a urinal and then disposed of the urine in the toilet. CNA #1 returned to assist CNA #2 with transferring Res #2 from bed to wheelchair. CNA #1 did not change their gloves or perform hand hygiene after the catheter care and before continuing to assist Res #2.A Perineal Care Policy and Procedure, updated May 2022, showed gloves should be worn to provide catheter care. Soiled supplies should be placed in the appropriate trash bag. The policy showed remove gloves, perform hand hygiene, and then don clean gloves before continuing…

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 record review and interview, the facility failed to develop a comprehensive care plan for diabetic monitoring for one (#9) of five residents reviewed for unnecessary medications. MDS coordinator #1 identified eight residents with diabetes. Findings: Res #9 was admitted with diagnoses which included type II diabetes mellitus. A physician order, dated 07/30/23, documented obtaining finger stick blood sugar if resident becomes symptomatic. A physician order, dated 07/30/23, documented offering a diabetic protein snack at bedtime. An admission assessment, dated 08/07/23, documented the resident was cognitively intact and received insulin. A physician order, dated 09/06/23, documented to administer Trulicity 0.75 mg/0.5 ml subcutaneously once a day on Thursdays for diabetes mellitus. A physician order, dated 01/11/24, documented obtaining finger stick blood sugar daily on Wednesdays. A care plan, reviewed 06/27/24, did not document Res #9's diabetic monitoring. On 06/27/24 at 11:30 a.m., MDS coordinator #1 stated they did not know diabetic monitoring needed to be included on 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.

Based on observation, record review, and interview, the facility failed to revise the care plan related to falls for one (#9) of three residents sampled for falls. The administrator identified 84 falls in the last six months. Findings: A Managing Falls and Fall Risk policy, revised March 2018, read in parts, .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of falling is identified as unavoidable . Res #9 had diagnoses which included Alzheimer's disease, seizures, and overactive bladder. A care plan, dated 08/08/23, documented the resident had the potential for falls secondary to balance problems during transition and walking, history of falls prior to admission, and routine antidepressant medication. The eight fall prevention…

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 record review and interview, the facility failed to ensure medications were coded accurately on MDS assessments for two (#1 and #3) of 12 sampled residents MDS were reviewed. The Administrator identified 43 residents who resided in the facility. Findings: 1. Resident #1 had diagnoses which included Alzheimer's disease. A Quarterly assessment, dated 04/22/24, documented Resident #1 received anticoagulant. There was no documentation the resident received an anticoagulant during the look back period. 2. Resident #3 had diagnoses which included acute cystitis. A Quarterly assessment, dated 04/01/24, documented Resident #3 received an antidepressant. There was no documentation the resident received an antidepressant during the look back period. On 06/27/24 at 11:24 a.m., MDS coordinator #2 stated they review the documentation in the EHR to ensure the MDS was coded accurately. They reviewed Resident #1 and #3's assessments and stated they were not coded accurate regarding their medications.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 39 residents resided in facility. Findings: On 06/19/23 at 8:25 a.m., a tour of the kitchen was conducted. The following observations were made: a. floor tiles were missing, b. oven hood lights were burned out and/or not working, c. there was an accumulation of brown and black residue on the floor under equipment, d. there was an accumulation of brown residue inside of the cabinets, e. there was an accumulation of brown and black residue on the dish machine, chest freezer, stove, three door reach in cooler, dish cart, and stand mixer, and f. there was an accumulation of lint on the oven hood filters. On 06/19/23 at 8:45 a.m., the CDM was asked how staff ensured the kitchen was kept clean and maintained in good repair. They stated they had a cleaning schedule and reported maintenance concerns to the maintenance director. The CDM was shown the above observations.

Based on record review and interview, the facility failed to ensure proper antibiotic stewardship was completed for two (#8 and #30) of two residents reviewed for antibiotic use. The Resident Census and Conditions of Residents form, dated 6/19/23, documented a census of 39. Findings: A facility Policy and Procedure for Proper Antibiotic Stewardship Program, read in part .the proper use of antibiotics while ensuring the safety and well-being of the residents .specific criteria, McGeer criteria, the facility has adopted for assisting in prescribing antibiotics .follow the McGeer criteria for assisting in the diagnosis of infections that require antibiotics . 1. Res #8's physician order, dated 02/04/23, documented the resident was to receive an antibiotic for 10 days due to cellulitis. The resident's MAR for April 2023 documented the antibiotic was completed per the physician orders. The clinical record did not document specific criteria to ensure the proper use of antibiotics was conducted. A quarterly assessment, dated 6/12/23, documented the resident had severely impaired cognition.…

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, record review, and interview, the facility failed to ensure a resident was treated with dignity during a transfer for one (#27) of one sampled resident observed for dignity. The Resident Census and Conditions of Resident report, dated 06/19/23, documented 39 residents resided in the facility. Findings: Res #27 had diagnoses which included acute cystitis without hematuria, osteoarthritis, HTN, and inflammatory spondylopathy. A quarterly resident assessment, dated 03/20/23, documented the resident required extensive assistance with transfers. On 06/20/23 at 11:07 a.m., CNA #1 was observed in the resident's room assisting them out of their recliner to their wheelchair. The resident was observed to bear weight by the CNA placing their hand under the resident's right arm. After the resident completed the pivot to their wheelchair the CNA was observed lowering the resident by their pants into their wheelchair. On 06/20/23 at 11:14 a.m., CNA #1 was asked when they transferred Res #27 from their recliner to their wheelchair, should they have assisted them by placing…

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 record review and interview, the facility failed to ensure there was sufficient documentation for basis of a resident discharge for one (#42) of one sampled resident review for discharge. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 39 residents resided in the facility. Findings: Res #42 was admitted to the facility on [DATE] with diagnoses which included burn of second degree of right and left foot, burn of second degree of right lower leg, presence of cardiac pacemaker, osteoarthritis, hypothyroidism, diabetes mellitus, hyperkalemia, HTN, heart failure, and COPD. A daily meeting minutes report, dated 04/12/23 at 8:55 a.m., documented Res #42 to discharge with a question mark behind their name. A nurse progress note, dated 04/12/23 at 1:12 p.m., documented the facility had a morning meeting concerning the behavior of the resident. It was documented a decision was made for the resident to be discharged from the facility. It was documented MDS coordinator #1 spoke…

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, record review, and interview, the facility failed to change and label oxygen tubing and concentrator reservoir according to physician orders for one (#11) of one residents sampled for respiratory treatments. The Resident Census and Conditions of Residents form dated 06/19/23, documented 39 residents resided in the facility. Findings: Res #11 had diagnoses which included COPD. A physician order, dated 04/29/23, documented to clean filter on oxygen concentrator and date bottle with time and initial. The order documented to change oxygen tubing with date and initials every Friday. An admission assessment, dated 05/06/23, documented the resident was cognitively intact, had shortness of breath, and received oxygen therapy. On 06/20/23 at 9:25 a.m., Res #11 was observed during a breathing treatment. The resident had oxygen delivered by nasal cannula at three liters per minute. The oxygen concentrator was observed at the foot of the bed. The concentrator humidification bottle was observed with a tape label on the bottle that documented 06/03/23. On 06/20/23 at 9:27…

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 record review and interview, the facility failed to ensure the results of the use of PRN pain medications were obtained for one (#36) of five sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 39 residents resided in the facility. It documented 21 residents were on a pain management program. Findings: Res #36 had diagnoses which included pain. A physician order, dated 03/28/23, documented hydrocodone-acetaminophen (pain medication) 7.5-325 mg one tab orally every six hours as needed. The April and May 2023 MARs were reviewed. There were no results for the administration of hydrocodone-acetaminophen on 04/19/23 and 05/22/23. On 06/20/23 at 10:01 a.m., the DON was asked what was the protocol for administering as needed pain medications. The DON stated the date, time, staff initials, medication, the reason the medication was administered, and the result should be documented on the back of the MAR. They were shown the resident's April and May 2023 MARs where there was no documented result on 04/19/23…

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 record review and interview, the facility failed to ensure side effects were monitored for the use of psychoactive medications for one (#36) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 31 residents who received psychoactive medications. Findings: Res #36 had diagnoses of anorexia, insomnia, and depression. Physician orders, dated 03/28/23, documented Lexapro (antidepressant medication) 20 mg once a day; Remeron (antidepressant medication) 15 mg at bedtime; and temazepam (benzodiazepine medication) 30 mg at bedtime. A care plan, dated 04/05/23, documented the resident was receiving Lexapro, Remeron, and temazepam. It was documented for staff to screen and observed for suspected side effects according to the behavior monitoring record. There was no documentation side effect monitoring was conducted for May 2023. On 06/20/23 at 10:01 a.m., the DON was asked to provide side effect monitoring documentation for the month of May 2023 for the resident's use of Lexapro, Remeron,…

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 of record review and interview, the facility failed to obtain physician ordered labs for one (#24) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 06/19/23, documented 39 residents resided in the facility. Findings: Res #24 had diagnoses which included congestive heart failure, hyperlipidemia, hypokalemia, and diabetes mellitus. A physician order, dated 02/07/23, documented CBC, CMP, and magnesium level on the 4th Wednesday of the month. There was no documentation the labs were obtained in April 2023 On 06/20/23 at 1:45 p.m., the DON was asked to locate documentation a CBC, CMP, and magnesium level was obtained in April 2023 for Res #24. On 06/20/23 at 3:00 p.m., the DON stated the labs were not collected in April 2023.