Retreat at Wellmore of Lexington

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Aug 13, 2026

  Based on review of facility policy, record review, and interview, the facility failed to initiate cardiopulmonary resuscitation (CPR) and/or life saving measures for Resident (R)47, for 1 of 1 resident reviewed for a closed record review for death. Specifically, on [DATE] at approximately 5:50 AM, R47 was found to be unresponsive with shallow breathing. Despite R47's full code status, CPR was not initiated and upon EMS arrival R47 was pronounced deceased at approximately 6:05 AM. On [DATE] at 12:10 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.24 - Quality of Life. On [DATE] at 5:55 PM, the facility provided an acceptable IJ Removal Plan. […]

• Immediate jeopardy, isolatedF760May 22, 2025

  Based on review of facility policy, record review and interview, the facility failed to ensure Resident (R)43 was free from significant medication error. Specifically, the facility failed to ensure that R43 received the correct medication order for Bupropion/Wellbutrin, which led to the resident being hospitalized . On 05/21/25 at 1:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 03/04/25. The IJ was related to 42 CFR 483.25 - Pharmacy Services. On 05/22/25 the facility provided an acceptable IJ Removal Plan. On 05/22/25 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. […]

• No harm, potential for more than minimal, widespreadF812Jan 31, 2024

  Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the refrigerator and dry storage were labeled and discarded after the manufacturer's expiration date. Findings Include: Review of the facility's policy titled, Food Receiving and Storage, with a revised date of [DATE], reveals, Food shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated. Such foods are rotated using a first in-first out system. Refrigerated/Frozen Storage: 7. […]

• No harm, potential for more than minimal, widespreadF812Feb 3, 2022

  Based on observations, staff interviews, and record review, the facility failed to ensure foods stored in the kitchen were labeled, dated, and not expired. These failures had the potential to increase the prevalence and spread of foodborne illness and infection to all facility residents. Findings include: Review of the [NAME] Baker Quality Control Checklist for Cleaning of Exhaust System dated [DATE], [DATE], [DATE], and a [DATE] email and on [DATE], cleaning was canceled and rescheduled for [DATE]. During a review of the facility's policy and procedures the following was revealed: The Refrigerators and Freezers policy stated .#7 All food shall be appropriately dated to ensure proper rotation by expiration dates . […]

• No harm, potential for more than minimal, patternF758Feb 3, 2022

  Based on observations, record review, staff interviews, review of the manufacturer's guidelines for medication use, and review of the facility's policy and procedures, the facility failed to ensure that three of five residents (Resident (R) R30, R41, and R42) reviewed for unnecessary medication use did not receive psychoactive medications without an appropriate assessment and indication for use, monitoring of adverse effects, attempting gradual dose reductions when appropriate, reducing or discontinuing as needed psychotropics past the 14 day criteria, identifying and routinely monitoring specific target behaviors, and developing and implementing resident specific non-pharmacological interventions. […]