Lexington Health Care Center

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and frequency, documentation, history and assessment, drug approach and right to refuse, drug-drug interaction and evaluation, and education and information. All regular staff Nurses and Medication Aides attended. All staff who do not work on a regular basis will be inserviced prior to starting their next shift.

Training is included for new hires in orientation completed by the Staff Development Coordinator.On 10/3/25

the consultant pharmacist was contacted and included in the facility's corrective action plan. The Consultant Pharmacist provided additional information to be used in training for the Nursing Staff and Medications Aides. This was incorporated into the skills fair on 10/7/26 and 10/8/25. Indicate how the facility will monitor its performance to make sure solutions are sustained.On 10/3/25 a plan was formulated by the facility's Quality Assurance Improvement team to implement the corrective action plan and monitor the plan through

the facility's quality assurance program.An individual med pass audit for all nurses and certified medication aides will be completed by the Director of Nursing or designee. This will be conducted on both the 7:00 AM to 7:00 PM shift and the 7:00 PM to 7:00 AM shift. This was initiated on 10/8/25. Each nurse or medication aide will be observed doing a complete medication pass. Audits will continue until all medication aides and nurses have been audited performing a complete medication pass.In addition to the above, medication

observations will be completed by the Director of nursing or designee on 5 licensed nurses and/or certified medication aides for 12 weeks following the initial audits.The Consultant Pharmacist will monitor all Morphine orders for clarity during her monthly review.On 10/9/2025 during monthly Quality Assurance Performance Improvement (QAPI) meeting with the IDT team, the Administrator or Director of Nursing will begin reviewing the plan above. Any changes will be made to the plan as necessary to maintain compliance with resident safety.Alleged date of compliance: 10/9/25 The facility's corrective action plan was validated by the following.On 10/10/25 nurses were observed administering medications. This included controlled substance medications and different forms of medications. Nurses were observed to administer medications correctly. Medications, which were observed administered, were reconciled to be correct with orders. Two residents, who were observed as nurses administered medications, voluntarily spoke up when

they observed that a surveyor was observing the nurses and made positive remarks about the nurse's abilities.Review of Resident # 1's Medication Administration MAR revealed a new order was obtained on 10/3/25 which was clear and transcribed to the MAR to denote that .25 ml of Morphine equated to the prescribed 5 mg.The facility provided documentation of inservice records per their plan of correction.Nurses from different shifts were interviewed and validated they had attended the education/skills fair and were able to speak of topics covered.Interview with the DON on 10/10/25 at 12:42 PM revealed that the audits were being conducted with every nurse and medication aide for an entire medication pass. The DON provided the audit tool and evidence of completion of multiple nurses who had been audited thus far. A

review of the audit tool revealed nurses were being checked off on 29 different itemsInterview with a Nurse

on 10/10/25 validated he had been one of the nurses who had completed an observation audit thus far.The facility's corrective action plan compliance date of 10/9/25 was validated.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lexington Health Care Center

17 Cornelia Drive Lexington, NC 27292

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, and staff interview the facility failed to ensure a resident's medical record was complete regarding medication orders given by a Nurse Practitioner and documentation of the administration of medications. This was for 1 of 3 of three sampled residents whose medications were reviewed (Resident # 1).The findings included: Resident # 1 was admitted to the facility on [DATE REDACTED] with a diagnosis of metastatic lung cancer disease.Review of a Nurse Practitioner's (NP) progress note for the date of 10/3/25 revealed

the NP had ordered some medications when the resident was not responding. According to the NP's note

she ordered two doses of Narcan and one dose of Lasix which were administered to the resident.Review of Resident # 1's orders revealed these orders were never entered into the resident's electronic record.

Review of Resident # 1's MAR (Medication Administration Record) revealed no documentation when these medications were given. They did not appear on the MAR. Review of the facility's emergency medication supply sign out records revealed Narcan was removed from the supply on 10/3/25 at 9:32 AM and 12:16 PM for Resident # 1. Lasix was removed from the emergency supply for Resident # 1 on 10/3/25 at 9:37 AM.Nurse # 5 was interviewed on 10/13/25 at 1:06 PM and reported the following information. There had been multiple nurses in the room with the Nurse Practitioner on 10/3/25 when the NP gave orders for the first dose of Narcan and the Lasix. This included Nurse Manager # 1, Nurse # 3, Nurse # 4, and herself (Nurse #5). The NP did not direct the order to any particular nurse, and it was not clear that she (the NP) did not enter the order in herself. Nurse # 4 had removed the Narcan and the Lasix from the backup supply and she (Nurse # 5) had administered Narcan and Lasix at the time these had been removed from the emergency supply. She had not documented the administration on the MAR.Nurse # 3 was interviewed on 10/13/25 at 1:10 PM and reported the following information. The NP had given the order for a second dose of Narcan on 10/3/25 around 12:30 PM. She had removed the Narcan from the backup supply and administered it per the verbal order. She had not documented the order on the MAR. When entering orders into the electronic medical record system, the system had choices of different medications and different forms in which the medications were supplied. She had tried to enter the order in the facility's electronic medical record system, but she could not find the correct form of Narcan in the electronic record as a choice. Therefore, the order was not entered into the resident's electronic record, and it never appeared on

the MAR. Therefore, she had not documented the administration, but she did administer it.According to interviews with the Administrator on 10/10/25 at 5:00 PM and again on 10/13/25 at 12:59 PM the Resident's record should have reflected the orders and administration times of the Narcan and Lasix.

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