Lexington Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lexington Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 17, 2025

  Based on observations, interviews, and record review, the facility failed to implement interventions and provide supervision to prevent accidents/injuries to residents related to: 1) failure to prevent a fall with injuries for one resident (#56) out of four residents reviewed for falls; and 2) failure to ensure a safe environment for residents to smoke for two residents (#21, #41) out of two residents who required the use of a wheelchair. Residents were expected to sign a leave of absence (LOA) form and then navigate off facility grounds, unassisted, through the parking lot approximately 350 feet, over a large speed bump, and across large potholes, despite being assessed to require supervision during ambulation or requiring the use of a wheelchair. Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF812Jul 17, 2025

  Based on observation and interviews, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner in one kitchen (Main) of one kitchens observed during survey.Findings included:During the initial tour of the kitchen conducted with the Certified Dietary Manager (CDM) on 07/14/2025 from 9:59 a.m. to 10:25 a.m., concerns were identified related to the following:The filter in the juice machine was observed with dirt and debris. An immediate interview with the CDM revealed she did not know how the filters can be cleaned. She stated they would have to order new filters and the vendor would install.The juice machine equipment was observed with brown - coloring and stains on the surface of the stainless-steel surfaces. […]

• No harm, potential for more than minimal, patternF677Jul 17, 2025

  Based on observation, interviews and record review, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) for five residents (#107, #86, #18, #43 and #102) of seven residents sampled.Findings included: 1. On 07/16/2025 at 9:13 a.m. Resident #107 was observed with long fingernails and hair on her chin. She stated she would like to be assisted with trimming her nails and shaving her face. She stated she preferred her nails short and clean. She stated the Certified Nursing Assistants (CNA’s) say they will help, but then they do not. […]

• No harm, potential for more than minimal, patternF690Jul 17, 2025

  Based on observations, interviews, and record review, the facility failed to provide incontinence care and prevent a Urinary Tract Infection (UTI) for one resident (#150) out of three residents sampled.Findings Included: During a phone interview on 07/15/2025 at 5:15 p.m., Resident #150 Family Member (FM) stated Resident #150 has been in and out of the hospital related to UTI's, multiple times. When she picks up Resident #150's laundry it is soaking wet. Maybe if they changed her more often, she would not have so many UTI's. When she goes to the hospital and they do lab work it shows E. coli [Escherichia coli] in her urine. Review of Resident #150's admission record revealed an admission date of 06/01/2022. […]

• No harm, potential for more than minimal, patternF880Jul 17, 2025

  Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infections as evidenced by 1) failure of staff to provide appropriate incontinence care by two staff members (Staff A, Staff B); 2) failure to implement policies related to staff use of artificial fingernails and containment of long hair for two staff members (Staff K, Staff S); and 3) failure to ensure staff donned Personal Protective Equipment (PPE) in a contact isolation room for two staff members (Staff AA, Staff AB) out of six staff members observed. […]