Care One at Lexington

In the surveyor’s words

From the most serious findings on record at Care One at Lexington, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 11, 2024

  Based on observations, record review, policy review and interviews, the facility failed to 1) prevent a fall resulting in a humeral (arm bone) fracture for one Resident (#19) and 2) ensure bed and chair alarms were in place for two Residents (#23 and #47) out of a total sample of 32 residents. Findings include: 1.) Review of the facility policy titled 'Falls and Fall Risk, Managing', dated as revised March 2018, indicated the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. […]

• Actual harm, isolatedF686Jun 15, 2021

  Based on observation, record review, policy review, and interview, the facility failed to 1. assess and implement treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . prevent the deconditioning of pressure ulcers for 2 Residents, (#17, #82) out of a total sample of 25 residents. Review of the facility policy titled Prevention of Pressure Injuries, revised 2020, indicated the following: * Assess the resident on admission for existing pressure injury risk factors and repeat weekly and upon any changes in condition. * Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living. * Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) * Reposition resident as indicated on the care plan. […]

• No harm, potential for more than minimal, patternF576Dec 24, 2025

  Based on record review and interviews the facility failed to ensure resident rights were maintained. Specifically, the facility failed to deliver mail from the US Postal Service on Saturdays, potentially impacting on the well-being of residents who are expecting mail. Findings include: Review of the facility's policy, dated revised May 2017, indicated the following: Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email and other electronic forms of communication confidentiality 4. Mail and packages will be delivered to the resident within twenty-four hours of delivery on premises or the facility's post office box (including Saturday deliveries). […]

• No harm, potential for more than minimal, patternF584Dec 24, 2025

  Based on observation and interview, the facility failed to provide a clean and homelike environment on one (the [NAME] Unit) of four resident units. Findings include:Review of the facility policy titled Homelike Environment, dated February 2021 indicated: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The surveyor observed the following on the [NAME] Unit on 12/23/25 at 10:31 A.M.: room [ROOM NUMBER]: Red stains on radiator and on chair. Large bowing stained ceiling tile. Large gouge in bathroom door. Room27: Deep scratches in flooring near the bed. room [ROOM NUMBER]: Stained flooring near toilet. […]

• No harm, potential for more than minimal, patternF584Dec 30, 2024

  Based on interview and observation, the facility failed to ensure it provided a homelike environment on the [NAME], [NAME], Minuteman, and [NAME] units. Findings include: 1. On 12/27/24 at approximately 2:15 P.M., on the [NAME] unit, the surveyor observed: - Cracked plastic paper towel holders in rooms #27, #28, and in the hallway men's room. - Sagging and broken ceiling tiles in rooms #26, #32, #33 and #35. - Worn wooden side dresser in room [ROOM NUMBER], worn dresser in room [ROOM NUMBER] - Broken bathroom wall measuring approximately 8 x 8 in room [ROOM NUMBER]. 41019 2. […]