Heritage Hall Lexington

In the surveyor’s words

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

• Actual harm, isolatedF658Sep 21, 2022

  Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to follow professional standards of quality for one of 17 residents in survey sample (Resident # 54). Nursing staff did not follow professional standards of clinical practice during medication administration. Resident #54 was not properly identified and was administered the roommate's medications in error. Resident #54 was sent to the emergency room and was admitted to the intensive care unit. Resident #54 developed [CONDITION(S)] (low blood pressure) & [CONDITION(S)] (low heart rate) which required intravenous (IV) fluids, medication, and continued telemetry (heart) monitoring. This indicated harm. […]

• Actual harm, isolatedF757Sep 21, 2022

  Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure one of 17 residents (Resident #54) was free from unnecessary medications. Resident #54 was administered her roommate's medications in error and was transferred to hospital, where she required treatment. This indicated harm. The findings were: Resident #54 was admitted to the facility with diagnoses, including but not limited to: unspecified kidney injury, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and dementia. The MDS (minimum data set) that was completed for Resident #54 was an OBRA Admission Assessment with an ARD (assessment reference date) of 07/02/2021. […]

• No harm, potential for more than minimal, patternF585Aug 28, 2025

  Based on observations, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation failed to post grievance information and failed to ensure an accurate grievance process for one resident, Resident #30 (R30) out of a survey sample of 19 residents. The findings included:1.The facility failed to ensure that grievance forms were readily available to residents and failed to identify and communicate who the designated grievance officer was at the facility. On 8/26/25 at 1:45 p.m., an observation was made in the facility. […]

• No harm, potential for more than minimal, patternF607Aug 28, 2025

  Based on staff interviews, facility documentation the facility staff failed to implement their abuse policy for prescreening potential employees for five of 25 records reviewed. The findings included:The facility failed to follow its abuse prevention and background check policies as evidenced by not obtaining reference checks for two employees, not completing registry checks for two employees, and hiring an employee with a felony barrier crime. On 8-27-25, an employee record review was conducted. During the review, it was identified that one employee had no reference checks completed, and another had two reference checks that were not completed. Two nurses had findings noted on their licenses, but the facility did not obtain information about those findings. […]

• No harm, potential for more than minimal, patternF761Aug 28, 2025

  Based on observation, staff interview, and facility documentation review, the facility staff failed to label and store medications appropriately in the one medication room and on one of two medication carts (pink hall cart). The findings included:On 8/26/25 at10:08 a.m., an observation/inspection was conducted of the medication storage room in the presence of licensed practical nurse #2 (LPN #2). Within the medication room storage cabinet with over-the-counter medications there was four full bottles of Oyster shell calcium 500 mg. Each bottle had 200 tabs each and all had an expiration date of 6/2025. Each bottle had a sticker that read [pharmacy name redacted] nurse consulting- medication expiring soon, please review. […]