Lexington House

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 24, 2023

  Based on observation, record review, and interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered plan of care, for 1 (#5) of 5 (#1, #3, #5, #6, & #7) sampled residents who received nutrition via a PEG (percutaneous endoscopic gastrostomy) tube. The facility failed to: 1. Ensure Resident #5's physician was notified of any signs or symptoms of infection when brown drainage was noted from a Peg-tube site. This deficient practice resulted in an actual harm for Resident #5 on 05/12/2023 at 6:37 p.m. […]

• No harm, potential for more than minimal, patternF803May 13, 2026

  Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the established recipes to ensure the nutritional adequacy of the meal for all 18 residents who received a puree diet.Findings:Review of a facility policy on 05/11/2026 at 3:15 p.m. titled, Standardized Recipes with a review date of 05/2023 revealed the following in part . Standardized recipes are used in preparation of food of control of quality, quantity, and uniformity of product. 5. The director of food and nutrition services requires the food and nutrition service staff to follow the standardized recipes. […]

• No harm, potential for more than minimal, patternF812May 13, 2026

  Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. The facility census was 110. Findings: Review of a facility policy on 05/11/2026 at 3:15 p.m. titled, Food Storage Labeling with a review date of 05/2018 revealed the following in part .The facility will ensure the safety and quality of food by adhering to proper storage and labeling procedure. 1. Labelling: A. All temperature-controlled foods and ready-to-eat foods that are prepared in the facility and held for longer than twenty-four hours will be labelled. Information included on the label: Name of the food and date of storage. 3. Rotation: A. […]

• No harm, potential for more than minimal, patternF805May 21, 2025

  Based on observations and interviews, the facility failed to ensure recipes for pureed diets were followed during meal preparation. This failed practice had the potential to affect 12 residents (#6, #11, # 36, #37, #46, #53, #58, #69, #71, #76, #85, and #101) who received pureed diets. Findings: Review of the Facility's lunch menu for 05/19/2025 revealed, in part .Barbeque ribs, macaroni and cheese, peas, green salad, and a roll. An observation on 05/19/2025 at 09:45 a.m. revealed a pan of pureed meat in the kitchen. S8 Dietary aide revealed meat was pureed prior to observation. S8 Dietary aide was observed pouring an unknown amount of peas in the electric food processor. S8 Dietary aide was observed not measuring portions or following the pureed recipe. […]

• No harm, potential for more than minimal, patternF812May 21, 2025

  Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. The deficient practice had the potential to effect all of the residents who received meals from the kitchen. There were 115 residents who resided in the facility. The facility failed to ensure: 1. Food items in the pantry were labeled with an open date; 2. Staff were wearing hair restraints including beard restraints to prevent hair from contacting food; 3. Maintenance of a clean and sanitary kitchen at all times; and 4. Dishes were sanitized appropriately. Findings: 1. Observation on 05/19/2025 at 8:40 a.m. […]