Inspection Reports for
Lexington Assisted Living

The complaint investigation was substantiated. The allegation involved neglect and lack of care and supervision due to failure to dispense prescribed medication, causing serious bodily injury to Resident #1.

The Department found that the facility failed to administer prescribed medication to Resident #1, resulting in a seizure requiring medical attention and hospitalization. The licensee was cited for violation of California Code of Regulations 87465(a)(4) and assessed civil penalties totaling $10,000, with $9,500 issued on this visit due to a prior penalty.

The inspection found that the centrally stored medication and destruction record was missing start dates on nearly all medications for Resident 1. Medications were not properly documented or administered as prescribed, posing an immediate health and safety risk. An immediate civil penalty of $1,000 was assessed for a repeat violation.

The visit followed a substantiated complaint investigation (complaint control number 29-AS-20210226132843) regarding Resident #1 sustaining multiple fractures while in care. The licensee was cited and previously issued an immediate civil penalty of $500 on February 24, 2022. The Department concluded that a civil penalty for serious bodily injury is warranted.

The Department determined that a civil penalty is warranted for serious bodily injury due to the facility's failure to provide proper care and supervision, resulting in multiple fractures from multiple falls. A civil penalty of $9,500 was issued following a prior immediate penalty of $500.

The visit was conducted in conjunction with a complaint investigation (Complaint Control # 29-AS-20240829092756).

Deficiencies were found related to medication management where a resident (R1) did not receive a prescribed seizure medication for 10 days, resulting in a seizure and hospitalization. Additionally, R1's Physician Report was incomplete due to a missing physician's signature.

The complaint investigation was initiated due to allegations of lack of supervision resulting in injury and failure to notify the resident's responsible party of an incident. The lack of supervision allegation was unsubstantiated, while the failure to notify allegation was substantiated.

The allegation of lack of supervision resulting in injury was found to be unsubstantiated due to insufficient evidence. However, the allegation that the facility failed to notify the resident's responsible party of an incident was substantiated, citing non-compliance with reporting requirements.

The facility was generally in good condition with no health or safety hazards noted in physical plant areas. However, two deficiencies were cited: missing medication dose start dates in centrally stored medication records, and hot water temperature exceeding regulatory limits in one resident bathroom. Plans of correction were submitted with due dates.

The visit was triggered by a complaint investigation (complaint control number 29-AS-20240829092756). The complaint involved a resident who had a medical emergency on or about 8/13/2024 and subsequently passed away on or about 8/20/2024. The facility did not report the incident or death to the licensing agency as required.

The facility failed to submit required incident and death reports to the licensing agency within the mandated timeframe, posing potential health, safety, or personal rights risks to residents in care.

The complaint included allegations of staff inappropriately handling a resident, not answering call lights timely, speaking inappropriately to a resident, inability to communicate with a resident, inadequate food quantity and quality, failure to assist with medication self-administration, and failure to provide shower assistance. The investigation determined most allegations were unsubstantiated except for failure to assist with medications and showering, which were substantiated.

The investigation found insufficient evidence to substantiate most allegations including inappropriate handling of a resident, untimely response to call lights, inappropriate speech by staff, communication barriers, and inadequate food quantity and quality. However, two allegations were substantiated: staff did not assist a resident with self-administration of medications as prescribed during the first days after move-in, and staff did not provide shower assistance as required during the first week of residency.

The complaint was received on 10/20/2023 alleging neglect and lack of care and supervision, including failure to provide medication to Resident #1 (R1) which allegedly contributed to R1's death, failure to attend to R1's requests timely, malfunctioning pendants, and ineffective communication with authorized representatives. The investigation concluded the medication and pendant allegations related to death and pendant malfunction were unsubstantiated, but the failure to provide prescribed medications and timely response to assistance requests were substantiated.

The investigation found insufficient evidence to substantiate allegations related to failure to provide medication contributing to R1's death, malfunctioning pendants, and ineffective communication with authorized representatives. However, the allegations that facility staff failed to provide certain prescribed medications (Buprenorphine, Ticagrelor, Aspirin) to R1 and failed to respond to R1's requests for assistance in a timely manner were substantiated. Deficiencies were cited related to medication administration and staffing levels impacting resident care.

The facility was generally found to be in compliance with health, safety, and regulatory requirements including physical plant conditions, kitchen safety, resident bedrooms, restrooms, and records. One deficiency was cited related to a medication record discrepancy involving a mismatched prescription number, which was corrected during the visit.

The complaint investigation was unannounced and conducted by Licensing Program Analyst Esther Cortez. Allegations included failure to provide adequate food service, failure to meet resident's medical needs, and failure to meet resident's hygiene needs. The food service and medical needs allegations were unsubstantiated, while the hygiene needs allegation was substantiated.

The investigation found insufficient evidence to substantiate allegations regarding inadequate food service and unmet medical needs. However, the allegation that staff failed to meet a resident's hygiene needs was substantiated due to false documentation of showering and lack of records verifying showers for the resident over a specified period.

The visit was complaint-related, triggered by two Unusual/Serious Incident Reports (SIRs) regarding residents eloping from the facility. Resident #1 eloped on 07/20/2023 and Resident #2 eloped on 07/31/2023. Resident #2's elopement was substantiated due to insufficient staffing and lack of monitoring.

The investigation found that Resident #1 eloped but does not have dementia and is allowed to leave unassisted, though staff had concerns about their safety. Resident #2, diagnosed with dementia and unable to leave unassisted, also eloped due to insufficient staffing and lack of monitoring. Deficiencies were cited for inadequate staffing and failure to update resident reappraisals and notify physicians of condition changes.

The complaint investigation was triggered by allegations including residents being left sitting in chairs all day, inadequate care and supervision, failure to safeguard personal items, residents not dressed in their own clothing, multiple falls sustained by a resident, failure to follow reporting requirements, and a scabies outbreak. The allegations regarding care, supervision, safeguarding personal items, and clothing were unsubstantiated. The allegations regarding multiple falls, failure to report incidents timely, and scabies outbreak were substantiated.

The investigation found the allegations that residents were left sitting in a chair all day, staff did not provide adequate care and supervision, staff did not safeguard residents' personal items, and residents were not dressed in their own clothing to be unsubstantiated. However, allegations that a resident sustained multiple falls, the facility did not follow reporting requirements, and the facility had scabies were substantiated.

The complaint alleged that staff were not following physician's orders for residents R1 and R2, specifically regarding timely administration of fentanyl patches and routine Morphine and Lorazepam medications. It also alleged staff did not answer residents' call lights timely. The fentanyl patch administration was not consistently done every 72 hours as prescribed, and medication administration records did not align. Staff failed to wake R2 to administer routine medications at prescribed times. The call light response allegation was found unsubstantiated.

The investigation substantiated that staff failed to follow physician's orders regarding medication administration for two residents, posing an immediate health and safety risk. However, the allegation that staff did not answer residents' call lights timely was unsubstantiated due to insufficient evidence.

The inspection found that resident R1 did not receive their prescribed Escitalopram 5 mg tablets on 2/17/22, 2/18/22, and 2/19/22 due to lack of medication refill, posing an immediate health risk. A deficiency was cited for failure to assist residents with self-administered medications as required.

Complaint investigation was substantiated for allegations that resident #1 was left soiled for a long period, did not have access to personal possessions, and was not provided meals on 2/19/22. Allegations regarding inoperable call button and untimely medication were unsubstantiated.

The investigation substantiated that resident #1 was left soiled for a long period, did not have access to personal possessions (hearing aids), and staff did not provide meals to the resident on 2/19/22. Allegations that the resident's call button was inoperable and that medication was not provided timely were unsubstantiated.

A deficiency was cited for storing disinfectants and toxic substances accessible to residents with dementia, posing an immediate health risk. A civil penalty of $250 was issued.

The complaint was substantiated regarding rough handling of residents causing extreme pain during toileting and transferring, but unsubstantiated regarding inappropriate speech by staff to residents.

The investigation substantiated that facility staff handled residents roughly while assisting with toileting and transferring, causing extreme pain but no injuries. The allegation that staff spoke inappropriately to residents was unsubstantiated.

The complaint was substantiated. The allegation involved resident #1 inappropriately touching female residents and making verbal advances. Interviews and observations confirmed these behaviors. Resident #1 denied the allegations during interview. Resident #2 could not be interviewed due to diagnosis. The licensee was found non-compliant with regulations protecting residents' personal rights.

The investigation substantiated that resident #1 engaged in inappropriate physical and verbal behavior towards other residents, violating their personal rights. Staff interviews and observations confirmed these behaviors, and the facility was cited for failing to protect residents from neglect and abuse.

The visit was triggered by complaint control #29-AS-20220726081704. The deficiency was substantiated with a zero-tolerance violation and a civil penalty was issued.

The inspection found that the gate leading to the facility's in-ground swimming pool was unlocked, posing an immediate health and safety risk to persons in care. A zero-tolerance violation was cited and a civil penalty of $500 was issued.

Two Type A deficiencies were cited: accessible dishwashing liquid in the memory care laundry room posing an immediate health risk, and employment of a staff member without prior criminal record clearance association, posing an immediate safety risk. Civil penalties totaling $3,250 were issued.

The complaint was substantiated based on interviews and observations that residents were missing medications when staff administered them, and staff admitted to distraction and omission.

The investigation found that residents were indeed not administered their medications as prescribed, with staff admitting to being distracted and forgetting to give medications. The allegation was substantiated.

The Licensing Program Manager discussed substantiated complaints and citations from the past three years and the Administrator's plans to maintain compliance. The Operations Manager described staffing status and new safety measures including delegated reporting, room sweeps, and secured medication/hazardous item storage.

The complaint investigation revealed that Resident #1's Needs and Services Plan had not been updated to reflect changes in condition after multiple falls and cognitive decline, despite residency beginning on 03/01/2020 and a recent fall on 04/21/2021. Additionally, staff member S1 was working without proper clearance and association with the facility.

The inspection found multiple deficiencies including accessible hazardous items to residents, unassociated staff working without proper clearance, failure to update resident Needs and Services Plans reflecting changes in condition, and improper storage of medications and dangerous items posing immediate health and safety risks.

The complaint was substantiated based on interviews and record reviews indicating that unqualified staff administered medication without current annual training.

The investigation substantiated that staff member S1 had not completed the required annual medication training, having last received training six years prior, which poses a potential health risk to residents.

The complaint investigation was substantiated based on findings that staff without medication training assisted residents, the facility lacked an Activities Director for over a month, and the internet was in disrepair causing intermittent outages.

The investigation substantiated that staff assisted residents with medications without proper training, the facility lacked an Activities Director for approximately a month, and the facility's internet was intermittently non-functional, posing potential risks to residents.

The facility was generally found to be in compliance with health and safety regulations, including clean and well-maintained bedrooms, restrooms, common areas, and kitchen. However, several deficiencies were noted related to accessible hazardous items to residents with dementia and outdated physician reports for some residents. Three citations were issued along with a civil penalty for repeat violations.

The inspection found multiple deficiencies including unsecured medications and toxic substances accessible to residents with dementia, centrally stored medicines not kept locked, and an unauthorized staff member working without proper association documentation. Civil penalties of $750 were issued.

The visit was a follow-up to a complaint control investigation #29-AS-20210910084322 conducted on 9/13/21. The deficiencies cited were related to unsafe storage of medications and toxic substances accessible to residents.

The licensee did not comply with regulations requiring that medications, cleaning supplies, and disinfectants be stored inaccessible to residents, posing an immediate safety risk. Items such as bleach, Tide pods, scissors, disinfectants, and resident medications were observed accessible to residents.

The complaint investigation was substantiated. The facility staff shut off the water supply for a prolonged period on May 20th from 10pm to 4am and did not provide advance notice to residents, posing potential health and safety risks.

The investigation substantiated both allegations: the water supply was shut off on May 20th from 10pm to 4am due to repairs, and the facility failed to provide advance notice to residents about the water shut-off. These failures posed potential health and safety risks to residents.

The visit was a follow-up to address deficiencies noted during a complaint investigation (control #29-AS-20210521142052).

During the facility tour, it was observed that a maintenance closet on the 3rd floor containing multiple gallons of paint was left ajar and accessible to residents, and a storage closet on the 2nd floor was open and unlocked, posing potential health and safety risks.

Visit was complaint-related, addressing deficiencies noted during complaint control #29-AS-20210521142052. Substantiation status is not explicitly stated.

During the facility tour, storage closets containing gallons of paint were found open and accessible to residents, posing a potential health and safety risk. Deficiencies were cited pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations.

The complaint was substantiated based on interviews and investigation findings that the facility failed to report a scabies outbreak affecting 5 residents and 8 staff, and did not notify the Department of Public Health as required.

The allegation was substantiated. The investigation found that the facility did not complete and submit incident reports or notify the Department of Public Health regarding the scabies outbreak affecting residents and staff.