Inspection Reports for Lexington Premier Nursing & Rehab
2770 PALUMBO DRIVE, LEXINGTON, KY, 40509
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
109 residents
Based on a September 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Deficiencies: 2
Date: Aug 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to residents' rights to a safe, clean, and homelike environment and to ensure nursing staff followed professional standards of quality in medication administration.
Findings
The facility failed to maintain a safe, clean, and homelike environment due to visibly stained and unraveled carpets in multiple areas. Additionally, nursing staff did not follow proper medication administration standards, as medications prepared by one nurse were administered by another, which was deemed unsafe by staff and leadership.
Deficiencies (2)
Failed to ensure residents had a right to a safe, clean, comfortable and homelike environment due to stained and unraveled carpet in multiple facility areas.
Failed to ensure nursing staff followed the standard of care for medication administration; medications prepared by one nurse were administered by another.
Report Facts
Medications prepared for Resident 57: 14
Quotes received for carpet replacement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 4 | Registered Nurse | Interviewed regarding importance of clean carpets |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding importance of facility cleanliness |
| Administrative Assistant | Administrative Assistant | Interviewed regarding facility safety and infection prevention |
| Chief Executive Officer | Chief Executive Officer | Interviewed regarding carpet replacement project and infection control awareness |
| North Unit Nurse Manager | Nurse Manager | Observed preparing medications for Resident 57 |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Observed administering medications prepared by another nurse |
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Interviewed regarding medication administration standards |
| Licensed Practical Nurse 10 | Licensed Practical Nurse | Interviewed regarding medication administration standards |
| Licensed Practical Nurse 12 | Licensed Practical Nurse | Interviewed regarding medication administration standards |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration expectations |
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 13
Date: Sep 5, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident care, safety, medication administration, staffing, and quality assurance.
Findings
The facility was found to have multiple deficiencies including failure to follow policies on advanced directives, protect residents from misappropriation of property, ensure safe resident transfers and discharges, complete required assessments, develop and implement effective care plans, provide adequate supervision to prevent elopements and falls, ensure timely physician visits, administer medications correctly, maintain adequate staffing levels, and operate an effective quality assurance program.
Deficiencies (13)
Failed to follow policy regarding advanced directives for one resident.
Failed to protect resident from misappropriation of property involving missing money and staff misconduct.
Failed to provide adequate transfer documentation and notification for one resident discharged to another facility.
Failed to complete required cognitive assessment (BIMS) on quarterly Minimum Data Set for one resident.
Failed to develop and implement effective care plans with individualized interventions for residents at risk for elopement and falls, resulting in multiple falls with injuries and one elopement.
Failed to ensure adequate supervision and monitoring to prevent elopements and falls for multiple residents.
Failed to ensure residents were seen by a physician as required for initial and subsequent visits for seven residents.
Failed to provide adequate nursing staff to meet resident needs and respond timely to call lights, resulting in extended wait times and insufficient supervision.
Failed to ensure residents were free from significant medication errors; one resident missed multiple insulin doses.
Failed to secure medications properly; needleless heparin flush left unsecured on resident's overbed table.
Failed to administer the facility in a manner that enabled effective use of resources to maintain resident well-being, including failure to prevent falls and elopements and ineffective quality assurance program.
Failed to designate a medical director responsible for implementation of resident care policies and coordination of medical care, including addressing falls and elopements.
Failed to set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Report Facts
Residents: 33
Falls: 57
Falls with major injury: 4
Missed insulin doses: 7
Resident census: 109
Staffing shortfall days: 17
Scheduled CNAs: 11
Scheduled CNAs: 10
Scheduled CNAs: 6
Residents requiring assistance: 59
Residents dependent for transfers: 36
Residents incontinent of bladder: 88
Residents incontinent of bowel: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #9 | Certified Nursing Assistant | Found Resident #1 at gas station after elopement and involved in medication error discussion |
| LPN #1 | Licensed Practical Nurse | Nurse on duty during Resident #1 elopement |
| CNA #10 | Certified Nursing Assistant | Noted Resident #1 missing and initiated Code Green |
| LPN #3 | Licensed Practical Nurse | Witnessed Resident #26 fall and re-educated resident |
| CNA #35 | Certified Nursing Assistant | Reported Resident #26 refused toileting assistance |
| LPN #14 | Licensed Practical Nurse | Found Resident #26 on floor and involved in fall investigations |
| Medical Director | Medical Director | Interviewed regarding falls, elopement, and QAPI involvement |
| Administrator | Administrator | Interviewed regarding QAPI and facility administration |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, staffing, and QAPI |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding QAPI and fall tracking |
| LPN #4 | Licensed Practical Nurse | Resident #1's nurse on 08/10/2023 and discussed medication administration |
| CNA #20 | Certified Nursing Assistant | Discussed staffing and supervision challenges |
| CNA #16 | Certified Nursing Assistant | Discussed staffing shortages and supervision challenges |
| LPN #7 | Licensed Practical Nurse | Discussed Resident #3 fall and supervision |
| CNA #5 | Certified Nursing Assistant | Responded to Resident #31 call light after delay |
| CNA #1 | Certified Nursing Assistant | Discussed staffing shortages and call light response |
| CNA #14 | Certified Nursing Assistant | Discussed staffing shortages and supervision challenges |
| LPN #9 | Licensed Practical Nurse | Discussed staffing and supervision challenges |
| LPN #11 | Licensed Practical Nurse | Discussed staffing and supervision challenges |
| LPN #8 | Licensed Practical Nurse | Responded to Resident #26 fall and called 911 |
| CNA #36 | Certified Nursing Assistant | Found Resident #26 on floor after fall |
Inspection Report
Census: 64
Deficiencies: 12
Date: Jan 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication management, nutrition, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to timely notify resident representatives of incidents, late submission of assessments, inadequate care planning, medication administration errors, inadequate supervision to prevent elopement, improper catheter and oxygen care, failure to maintain nutritional status, and improper food storage.
Deficiencies (12)
Failure to immediately notify the resident's representative of an accident involving the resident which resulted in injury.
Failure to submit the initial admission Assessment within the required fourteen (14) day period.
Failure to develop the baseline care plan within forty-eight (48) hours for four sampled residents.
Failure to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals.
Failure to provide enough food/fluids to maintain a resident's health.
Failure to provide safe and appropriate respiratory care for residents requiring oxygen therapy.
Failure to provide safe, appropriate dialysis care/services for a resident who requires such services.
Failure to provide pharmaceutical services to meet the needs of each resident and ensure timely medication administration.
Failure to ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles and stored properly.
Failure to provide safe and appropriate supervision to prevent accidents and elopement.
Failure to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards.
Report Facts
Residents sampled: 64
Weight loss percentage: 28
Missed medication doses: 3
Missed medication doses: 4
Weekends without RN coverage: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in relation to failure to notify about resident elopement alarm and medication administration |
| LPN #11 | Unit Manager South | Named in relation to care plan and medication management expectations |
| LPN #20 | Licensed Practical Nurse | Named in relation to medication administration and dietary communication |
| KMA #32 | Kentucky Medication Aide | Named in relation to medication availability and administration |
| DON | Director of Nursing | Named in relation to oversight of care plans, medication, and staffing |
| Administrator | Named in relation to facility oversight and expectations | |
| Medical Director | Named in relation to medication orders and resident care | |
| CNA #40 | Certified Nursing Assistant | Named in relation to resident care and observations |
| RN #1 | Registered Nurse | Named in relation to resident supervision and care planning |
| LPN #15 | Licensed Practical Nurse | Named in relation to medication cart management |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 20, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the use and care of feeding tubes and the proper labeling and storage of medications, including insulin pens, at Lexington Premier Nursing & Rehab.
Findings
The facility failed to ensure appropriate care and labeling of enteral feeding tubes for two residents, including missing required information on feeding bag labels. Additionally, the facility failed to properly label and date insulin pens stored in medication carts, making it impossible to determine expiration dates.
Deficiencies (2)
Failure to properly label enteral feeding bags with resident identification, type of formula, date/time prepared, rate of administration, and nurse's initials for Residents #87 and #300.
Failure to label insulin pens with the date removed from refrigeration, preventing determination of expiration dates.
Report Facts
Residents sampled: 9
Residents affected: 2
Feeding bag change frequency: 24
Feeding infusion rates: 45
Feeding infusion rates: 75
Insulin storage duration unopened: 28
Insulin storage duration unopened: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Documented changing Resident #87's gastric tube enteral feeding bag and tubing; interviewed about labeling requirements |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Documented changing Resident #300's gastric tube enteral feeding bag and tubing; interviewed about labeling requirements |
| Rehabilitation Nurse Manager | Nurse Manager | Interviewed regarding facility policy on enteral feeding formula labeling and hang times |
| Acting Director of Nursing | Director of Nursing | Interviewed about importance of labeling enteral feeding bags and bottles |
| Administrator | Administrator | Interviewed about expectations for proper labeling of enteral feeding bottles or bags and medication storage |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed about insulin pen storage and inability to use undated pens |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about checking insulin date when administering to residents |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed about insulin pen storage requirements |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about insulin pen storage and risks of leaving pens out of refrigerator |
| Facility Pharmacist | Pharmacist | Interviewed about insulin expiration dating and storage requirements |
| Interim Director of Nursing | Director of Nursing | Interviewed about medication storage expectations and insulin dating requirements |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 1, 2018
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide care by qualified persons according to each resident's written plan of care, appropriate catheter care, and infection prevention and control practices.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to provide care according to the resident's plan, failed to secure urinary catheters properly, and failed to maintain infection control standards. The complaint was substantiated based on observations and interviews.
Findings
The facility failed to ensure services were provided by qualified persons according to the resident's plan of care, specifically failing to secure an indwelling urinary catheter with a leg strap as required. Additionally, poor infection control practices were observed during catheter care, including inadequate handwashing and glove use, which increased the risk of infection.
Deficiencies (3)
Failure to provide care by qualified persons according to each resident's written plan of care, specifically failure to secure indwelling urinary catheter tubing with a leg strap.
Failure to provide appropriate care to prevent excessive tension on the catheter, risking urethral tears or dislodgement.
Failure to establish and maintain an infection prevention and control program, including poor handwashing and glove use during pericare and catheter care.
Report Facts
Residents sampled: 20
Residents affected: 1
BIMS Score: 7
Foley catheter size: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #1 | State Registered Nurse Aide | Performed catheter care without securing catheter and failed to follow infection control procedures |
| LPN #2 | Licensed Practical Nurse | Provided interview confirming expectations for catheter securement and infection control |
| RN #4 | Registered Nurse/Quality Improvement Nurse/Infection Control Nurse | Provided interview on infection control expectations and facility policies |
| Director of Nursing | Director of Nursing | Provided interview on expectations for catheter securement and infection control adherence |
| Administrator | Administrator | Provided interview on expectations for staff adherence to care plans and infection control policies |
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