Hartland Park Health & Rehabilitation
Hartland Park Health & Rehabilitation in Lexington, KY — inspection on November 24, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R1's three documents Hospital Discharge summary, dated [DATE], 09/21/2025, and 10/18/2025 revealed R1 was readmitted to the hospital, after each incident, with vomiting and the inability to swallow liquids.
Per the summaries, R1 had an esophageal obstruction, chronic dysphagia, chronic esophageal strictures, and gastroesophageal reflex disease (GERD).
Each time, Gastroenterology was consulted. R1 had an EGD on 10/17/2025 with removal of food from the upper esophagus as well as dilation of the esophagus. In continued interview with Certified Nurse Aide (CNA) 2, from Unit B, on 10/22/2025 at 1:08 PM, she stated R1 resided on Unit C, and she did not know where to find care plan information on Unit C.
She stated she did not receive any information in report concerning R1's behavior of trying to obtain regular food. In an interview with the Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator on 10/22/2025 at 10:10 AM, she stated CCPs were updated quarterly or as needed for a change.
She stated the Unit Manager could update the care plan.
She stated she attended the interdisciplinary morning meeting and made changes to the care plan.
She stated the other disciplines were responsible to make changes to their specific care plan area and make the changes timely. In an interview with the Director of Nursing (DON) on 10/23/2025 at 10:29 AM, she stated care plans were updated in the interdisciplinary team clinical meeting and as needed, too.
She stated the different disciplines could update the care plan as needed.
She stated R1's care plan should have been updated in 09/2025.
She stated the Quality Assurance and Performance Improvement (QAPI) committee, at their meeting, discussed the event with R1 and formulated a plan of action. In an interview with the Administrator on 10/22/2025 at 2:32 PM, she stated she had been informed about the events of R1 choking on food.
She stated the CCP interventions should be to pick up trays before R1 could collect food off another resident's tray; and R1 to sit with staff supervision at the assisted table at meals, and the daughter, when she visited, would take him over to the male residents table to talk with his friends.
She stated R1's daughter voiced no concern to them and stated he just had dementia.
She stated R1's Activity Care Plan intervention should be not to give popcorn.
She stated the concern with R1's non-compliance in food choices resulted in hospital stays.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Hartland Park Health & Rehabilitation
1500 Trent Boulevard Lexington, KY 40515
SUMMARY STATEMENT OF DEFICIENCIES
In an interview with the Registered Dietitian (RD) Licensed Dietitian (LD) on 10/22/2025 at 4:00 PM, she stated she was made aware of the incidents when R1 was offered or asked for foods from other residents.
She stated R1 had an esophageal stricture and had the esophageal area stretched as needed.
She stated foods not allowed on a pureed diet included popcorn, a granola bar, and pineapple. In an interview with the Speech Therapist on 10/21/2025 at 1:33 PM, she stated she had seen R1 for cognition and speech.
She stated, at the time of the evaluation, she was not aware there were any concerns with R1's swallowing.
She stated she asked the daughter about that, and she told her there were no concerns with his swallowing.
She stated a Speech reevaluation was done on 10/02/2025, and there were no concerns for swallowing.
She stated with R1, all foods were pureed, with no whole foods allowed on the diet.
She stated she followed the orders from the Hospital Discharge Summary for R1 to follow a pureed diet. In an interview with the Director of Nursing (DON) on 10/22/2025 at 3:00 PM, she stated R1 did not move around as much as he used to.
She stated he took himself to the dining room (DR) and would return.
She stated she was told RN1 found a granola bar in his room and got it away from him.
She stated the incident about the popcorn occurred while doing activities, and activities reported that to nursing.
She stated the Activity Director instructed the residents not to share food with others.
She stated R1 was quick to take food off the other residents' trays when the opportunity was available at the other or his own table.
She stated he liked to sit with his male resident friends, and they would offer him food.
The DON stated they had educated staff that R1 needed to stay at the assist table to be monitored, and staff was to sit and supervise him.
The DON stated R1's last esophageal stent placement was on 05/22/2024, and R1 had received several esophageal dilatations over the years as his esophagus needed to be stretched. In an interview with the Administrator on 10/22/2025 at 2:32 PM, she stated she had been informed about the events of R1 choking on food.
She stated the CCP interventions should be to pick up trays before R1 could collect food off another resident's tray; and R1 to sit with staff supervision at the assisted table at meals, and the daughter, when she visited, would take him over to the male residents table to talk with his friends.
She stated R1's daughter voiced no concern to them and stated he just had dementia.
She stated R1's Activity Care Plan intervention should be not to give popcorn.
She stated the concern with R1's non-compliance in food choices and staff not preventing it resulted in hospital stays.
Facility ID: