Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
43% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 9, 2025
Visit Reason
An off-site follow-up survey was initiated and concluded to verify correction of previously identified deficiencies.
Findings
The facility was determined to have corrected their deficiencies as alleged based on the implementation of an acceptable Plan of Correction.
Inspection Report
Routine
Deficiencies: 2
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to assess compliance with food safety and infection prevention and control standards at Lexington Country Place nursing home.
Findings
The facility failed to prepare and serve food under sanitary conditions, including improper drying and stacking of dome lids, inaccurate food temperature checks, and inadequate hand hygiene and glove use. Additionally, the facility failed to post enhanced barrier precaution signage outside rooms of residents with active orders, risking infection control breaches.
Deficiencies (2)
F 0812: The facility failed to prepare and serve food under sanitary conditions, including stacking wet dome lids, inaccurate temperature checks of puree food, and staff not performing proper hand hygiene when changing gloves.
F 0880: The facility failed to implement an infection prevention and control program by not posting enhanced barrier precaution signage outside rooms of 5 residents with active orders, risking transmission of infections.
Report Facts
Residents affected: 5
Residents sampled: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food and Beverage Director | Interviewed regarding food temperature checks and glove use | |
| Registered Nurse Director of Nursing | Interviewed regarding expectations for safe food handling practices | |
| Administrator | Interviewed regarding concerns about bacterial growth and infection control signage | |
| Infection Preventionist Nurse | Interviewed regarding infection control signage and orders | |
| Certified Nurse Assistants (CNA4, CNA5, CNA6) | Interviewed regarding reliance on signage for PPE use | |
| Staff Development Coordinator | Interviewed regarding infection control signage procedures | |
| Physical Therapist | Interviewed regarding importance of signage for infection control | |
| Minimum Data Set Nurse | Interviewed regarding infection control orders and signage |
Inspection Report
Annual Inspection
Census: 85
Capacity: 111
Deficiencies: 10
Date: Apr 2, 2025
Visit Reason
Annual Life Safety Recertification Survey conducted to assess compliance with Medicare and Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency lighting testing, exit signage, kitchen hood extinguishing system maintenance, smoke barrier integrity, electrical safety, fire drills, fire door inspections, portable space heater use, food safety, and infection prevention and control practices.
Deficiencies (10)
Failed to provide documentation for monthly 30-second and annual 90-minute emergency battery lighting testing.
Failed to install 'Not an Exit' signage on an exterior door leading to a courtyard.
Failed to maintain kitchen hood extinguishing system and complete semi-annual inspections.
Failed to ensure smoke barriers restrict smoke transfer due to cable and piping penetrations and missing drywall.
Failed to install PTAC unit power cord end in accordance with NFPA standards, exposing wiring.
Failed to conduct quarterly fire drills on all shifts; missing documentation for second shift fire drill in Q2 2024.
Failed to inspect fire doors annually as required by NFPA 80 standards.
Failed to ensure portable space heaters comply with NFPA standards; electric fireplace heat element not verified to be below 212°F.
Failed to prepare and serve food under sanitary conditions including wet stacked dome lids, improper hand hygiene with glove use, and inaccurate food temperature monitoring.
Failed to establish and maintain an infection prevention and control program; residents on Enhanced Barrier Precautions lacked proper signage and PPE outside rooms.
Report Facts
Deficiencies cited: 10
Facility capacity: 111
Census: 85
Fire drills missed: 1
Fire doors inspected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facilities Director | Named in multiple findings including emergency lighting, exit signage, kitchen hood maintenance, smoke barrier penetrations, PTAC wiring, and fire door inspections. | |
| Maintenance Director | Named in findings related to emergency lighting, kitchen hood inspections, smoke barrier penetrations, and fire door inspections. | |
| Food and Beverage Director | Named in food safety deficiencies including improper food temperature monitoring and hand hygiene. | |
| Administrator | Named in multiple interviews verifying findings and overseeing corrective actions. | |
| Director of Nursing | Named in infection prevention and control deficiencies and corrective actions. | |
| Infection Preventionist Nurse | Named in infection control deficiencies and staff training. | |
| Minimum Data Set Nurse | Named in infection control deficiencies and order reviews. |
Inspection Report
Deficiencies: 0
Date: Jan 23, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Lexington Country Place, related to a regulatory survey completed on 2020-01-23.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 31, 2019
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to develop and implement individualized care plans for residents with dementia, improper catheter insertion technique, medication storage and labeling issues, unsanitary food preparation conditions, incomplete and inaccurate medical records, outdated infection control policies, and failure to maintain glucometer control solutions according to manufacturer recommendations.
Deficiencies (8)
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for a resident with dementia, neglecting individualized interventions and meaningful activities.
F 0690: The facility failed to ensure sterile technique during indwelling urinary catheter insertion and allowed unlicensed staff to attempt catheter reinsertion, risking infection.
F 0744: The facility failed to provide person-centered dementia care that maximized dignity, autonomy, and socialization for a resident diagnosed with dementia.
F 0761: The facility failed to ensure proper storage of drugs and biologicals, including medication refrigerator temperatures out of range and presence of loose, unlabeled pills in medication carts.
F 0812: The facility failed to prepare and store food under sanitary conditions, including lack of paper towels at sinks, scoops left inside food bins, and soiled nutrition refrigerators.
F 0842: The facility failed to maintain complete and accurate medical records, including failure to input wound care physician orders and treatment plans into the electronic medical record, resulting in conflicting orders.
F 0880: The facility failed to provide and implement an infection prevention and control program, including failure to use sterile technique during catheter insertion and failure to update infection control policies annually.
F 0908: The facility failed to maintain patient care equipment safely by not dating glucometer control solution vials when opened, risking inaccurate blood glucose readings.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents affected: 1
Medication carts observed: 6
Loose pills found: 15
Medication refrigerator temperature: 42
Activities goal: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #2 | State Registered Nurse Assistant | Attempted to reinsert urinary catheter without success and outside scope of practice |
| LPN #2 | Licensed Practical Nurse | Failed to use sterile technique and test retention balloon during catheter insertion |
| Activity Director | Acknowledged need for more specific, person-centered dementia activity care plans | |
| Interim Director of Nursing | Stated expectation for individualized dementia care and proper catheter insertion | |
| Unit Manager for Magnolia Unit | Stated SRNAs should not insert catheters and emphasized sterile technique | |
| Director of Nursing (DON) | Emphasized sterile catheter insertion by licensed nurses and annual infection control policy review | |
| Administrator | Stated expectations for care plan development, sterile catheter insertion, medication storage, and infection control | |
| LPN #9 | Licensed Practical Nurse | Reported night shift responsibility for medication refrigerator temperature checks |
| LPN #10 | Licensed Practical Nurse | Reported loose, unlabeled pills in medication cart |
| LPN #11 | Licensed Practical Nurse | Reported loose, unlabeled pills in medication cart |
| Dietary Aide #1 | Reported lack of paper towels and improper scoop storage in kitchen | |
| Dietary Supervisor | Reported staff responsibility for paper towel restocking and scoop storage | |
| Registered Dietitian (RD) | Emphasized infection control importance of paper towels and scoop storage | |
| Wound Care Nurse | Acknowledged failure to input wound care orders into EMR and conflicting orders | |
| RN #1 | Registered Nurse | Performed glucometer testing and dated control solution boxes |
| LPN #7 | Licensed Practical Nurse | Reported night shift glucometer testing and importance of dating control solution vials |
| LPN #3 | Licensed Practical Nurse | Reported importance of glucometer control testing and dating solution vials |
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