Lexington Health Care Center: Missing Medication Records - NC
That is what federal inspectors found when they investigated Lexington Health Care Center following a complaint this October.
The patient, identified in inspection records only as Resident 1, had been admitted to the facility with a diagnosis of metastatic lung cancer. On October 3, 2025, a nurse practitioner documented in a progress note that the resident was not responding. She ordered two doses of Narcan, a drug used to reverse opioid overdose or sedation, and one dose of Lasix, a diuretic. According to her own note, all three doses were administered that day.
The emergency supply sign-out log confirmed the drugs were removed. Narcan was pulled at 9:32 AM and again at 12:16 PM. Lasix was pulled at 9:37 AM. All three withdrawals were logged to Resident 1.
None of it appeared in the resident's electronic medical record. None of it appeared on the medication administration record.
The facility had multiple nurses in the room when the nurse practitioner gave her initial orders. Nurse Manager 1 was there. So were Nurse 3, Nurse 4, and Nurse 5. When Nurse 5 was interviewed by inspectors on October 13, she described a scene where the nurse practitioner did not direct her order to any particular nurse, and nobody was certain whether the NP intended to enter the order herself. Nurse 4 pulled the Narcan and Lasix from the backup supply. Nurse 5 administered them. She told inspectors she had not documented the administration on the medication record.
The second dose of Narcan came around 12:30 PM, after the situation had not resolved. This time it was Nurse 3 who pulled the drug and gave it. She told inspectors she had tried to enter the order into the facility's electronic records system but could not find the correct form of Narcan as an available option in the system's menu. Because she could not find it, she did not enter it. Because it was not entered, it did not appear on the medication record. She administered the drug anyway and documented nothing.
Four nurses and a nurse manager were present for at least part of this. The emergency supply log captured what was removed and when. The nurse practitioner's own progress note described the orders and stated the medications were given. The administration happened. The record said otherwise, showing nothing at all.
The facility's administrator acknowledged the problem in two separate interviews with inspectors, on October 10 and again on October 13. The resident's record, the administrator said, should have reflected both the orders and the times the medications were administered.
Inspectors classified the violation as causing minimal harm or potential for actual harm, the lower end of the severity scale. The deficiency was cited under the standard requiring facilities to maintain complete and accurate medical records.
What the record could not answer, and what the inspection report does not address, is whether anyone reviewing Resident 1's chart in the hours or days after October 3 would have known those drugs had been given at all. A patient with metastatic lung cancer, not responding, given Narcan twice in the span of three hours, and the chart reads as though none of it happened.
The nurse practitioner noted it. The supply log captured it. The nurses remember it. The medical record, the document that follows a patient through every subsequent treatment decision, contained none of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lexington Health Care Center from 2025-10-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
Lexington Health Care Center in Lexington, NC was cited for violations during a health inspection on October 13, 2025.
That is what federal inspectors found when they investigated Lexington Health Care Center following a complaint this October.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.