Kendal at Lexington

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 24, 2024

  Based on staff interview, facility document review, and clinical record review, the facility failed to provide staff assistance and supervision for a safe transfer for one of sixteen residents (Resident #1), resulting in a fall with fracture (harm). The findings include: Resident #1 (R1) fell when a privately hired companion/sitter attempted to transfer R1 from the bed to a wheelchair. The private companion did not request facility staff assistance with the transfer and had no prior documented training of facility policies that prohibited private caregivers/companions from performing direct-care activities, including transfers. […]

• No harm, potential for more than minimal, widespreadF880Apr 24, 2024

  Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections having the potential to affect residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to respond to and implement quarantine and testing measures in accordance with CDC (The Centers for Disease Control and Prevention) recommendations to manage COVID-19 during an outbreak affecting 1 of 2 units. On 4/22/24 at 4:19 p.m., and again on 4/23/24 at 08:35 a.m., interviews were conducted with the facility's infection preventionist (IP). […]

• No harm, potential for more than minimal, patternF812Apr 24, 2024

  Based on observation, staff interview and facility document review the facility staff failed to prepare, store, and distribute food in a sanitary manner. The finding included: The dietary staff failed to label open food with an open date and the use by date, failed to dispose of out of date products, failed to ensure metal serving pans were dry before nesting, failed to clean the grill after use, failed to clean trays in the refrigerator after spills occurred, failed to hold proper food temperatures on the steam tables on the units, and failed to ensure beard guards were worn by applicable staff. On [DATE] at 10:59 AM, observations were made in the main kitchen during a tour with the dietary manager (other staff #5, OS#5). […]

• No harm, potential for more than minimal, patternF881Apr 24, 2024

  Based on staff interview, clinical record review and facility documentation review, the facility staff failed to maintain an antibiotic stewardship program to monitor antibiotic use for three residents (Resident #1- R1, Resident #34- R34, and Resident #27- R27) in a survey sample of 3 residents reviewed for antibiotic use. The findings included: On 4/23/24 at 08:48 a.m., an interview was conducted with the facility's infection preventionist (IP). The IP was asked about the antibiotic stewardship program and was asked to explain the facility's process. The IP reported that she doesn't track any infections other than COVID-19. […]

• No harm, potential for more than minimal, patternF690Jan 31, 2023

  Based on staff interview and clinical record review, the facility staff failed to provide care and services for a Foley catheter as ordered by the physician for one of six residents in the survey sample (Resident # 1). Findings include: Resident #1 had an order to change the Foley catheter once every three weeks, but the medical device went unchanged for three months. Resident #1 was added to the survey sample as a closed record review, as there were no current residents with a catheter, Resident # 1 was admitted to the facility 2/25/22 with a readmitted [DATE]. […]