Lexington Country Place

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580May 1, 2026

  Based on interviews, record review, and review of the facility's policy, the facility failed to promptly notify the physician of a fall for 1 of 8 residents sampled for falls, Resident (R) 13. Record review and interviews revealed R13 sustained a fall on 03/08/2026 at approximately 8:00 PM. R13 was observed to have a significant change in condition related to her physical functioning, mobility, and pain level. Record review revealed, however, the resident's physician was not notified promptly of these changes until the resident's family requested staff to contact the physician. […]

• Immediate jeopardy, isolatedF689May 1, 2026

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents received adequate supervision and failed to keep residents free from falls for 1 of 8 sampled residents reviewed for falls, Resident (R) 13.Record review revealed R13 sustained a total of 10 falls from 12/29/2025 to 04/25/2026, including some with a documented injury. For one fall, on 03/08/2026, R13 suffered a non-displaced fracture of the right femur, extending to the resident's right knee. R13 was subsequently transferred to the emergency department and later returned to the facility on [DATE] and sustained a fall after transfer. Subsequent falls continued following hospitalization and surgical intervention. […]

• Actual harm, isolatedF684May 1, 2026

  Based on interview, record review, and review of the facility's policies, the facility failed to ensure a resident received necessary care and services following a fall when staff failed to perform a thorough assessment, failed to accurately evaluate and document pain, and failed to obtain timely diagnostic services, resulting in a delay in identification of a femur fracture, for 1 of 8 sampled residents, Resident (R) 13. Refer to F580 and F689The findings include:Review of the facility's policy titled, Quality of Care, revised 08/01/2024, revealed the residents received treatment and care by qualified persons in accordance with professional standards of practice. […]

• No harm, potential for more than minimal, widespreadF812Apr 3, 2025

  Based on observation, interview, review of the United States Department of Agriculture (USDA) web page, review of the facility's signage, and review of the facility's procedure, the facility failed to prepare and serve food under sanitary conditions as determined by observations during the initial kitchen tour and return tours. Observation on 04/01/2025 and on 04/02/2025 revealed dome lids were stacked wet. Observation on 04/01/2025 of food temperatures for the lunch service revealed an inaccurate temperature for puree food, but it was placed on the tray line for service. Additionally, observation on 04/02/2025 revealed staff changed gloves and performed tasks without proper hand hygiene. […]

• No harm, potential for more than minimal, patternF584May 1, 2026

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 25 sampled residents, Resident (R) 6, R13, R14, R26, and R93.Observations on 04/27/2026 and 04/28/2026 revealed in five resident rooms the privacy curtain was in disrepair. Further observation revealed trash on a bedside table and the floor, including used mouth swabs and a contaminated dressing and gloves; debris accumulation around the baseboards; and soiled bed linens on a bed.The findings include:Review of the facility's undated policy titled, Resident's Rights, revealed the resident had the right to be treated with consideration, respect, and recognition of their dignity and individuality.The State Survey… […]