Lexington Premier Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Lexington Premier Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF656Sep 5, 2023

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to develop and implement care plans with individualized person-centered interventions, to include adequate supervision and monitoring for residents at risk for elopement; and for residents with a history of falls, for seven (7) of thirty-three (33) sampled residents (Residents #1, #3, #18, #22, #24, #25, and #26). 1. Resident #1 eloped from the facility on 07/27/2023 without staffs' knowledge. The resident disabled a window alarm in his/her room and climbed out the window. Resident #1 was found at a nearby convenience store approximately forty-five (45) minutes later. […]

• Immediate jeopardy, patternF689Sep 5, 2023

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure adequate supervision and monitoring to prevent elopements for one (1), Resident #1; and falls for six (6), Residents #3, #18, #22, #24, #25 and #26, of thirty-three (33) sampled residents. 1. On 04/20/2023, Resident #1 attempted to exit the building by walking out of the front door of the facility. At that time, the facility failed to assess the resident's cognition and placed a Wander Guard bracelet on the resident, as a measure to prevent elopement. Further, the facility failed to have a system in place to ensure the resident's window alarm, which alerted staff when opened, was checked routinely. […]

• Immediate jeopardy, patternF835Sep 5, 2023

  Based on interview, record review, review of the facility's Plan of Correction (POC) from the 01/28/2023 Recertification Survey, and review of the facility's Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the 01/28/2023 Recertification Survey's Plan of Correction (POC), revealed the facility was previously cited at actual harm and Immediate Jeopardy (IJ). The 09/05/2023 survey had repeat deficiencies that had been cited on the 01/28/2023 survey. […]

• Immediate jeopardy, patternF867Sep 5, 2023

  Based on interview, record review, review of the facility's policy, and review of the facility's Plan of Correction (PoC) for the survey completed on 01/28/2023, with a compliance date of 04/11/2023, it was determined the facility failed to have an effective system to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. The facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to effectively track adverse resident events, analyze their causes, and implement preventative action(s). […]

• Immediate jeopardy, isolatedF656Jan 28, 2023

  Based on observation, interview, record review, review of the facility's policies, and investigations, it was determined the facility failed to ensure the Comprehensive Care Plan was developed and/or implemented for six (6) of sixty-four (64) sampled residents (Residents #1, #23, #57, #71, #255, and #348). 1. The facility admitted Resident #1 on 11/12/2022 with a diagnosis of Dementia with Agitation. Resident #1's initial Nursing Assessment, dated 11/12/2022, revealed the facility assessed Resident #1 not to be an elopement risk. […]