Lexington Health Care Center
Lexington Health Care Center in Lexington, NC — inspection on October 13, 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
will monitor all Morphine orders for clarity during her monthly review.On 10/9/2025 during monthly
necessary to maintain compliance with resident safety.Alleged date of compliance: 10/9/25 The
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.
345419 10/13/2025
Lexington Health Care Center 17 Cornelia Drive Lexington, NC 27292
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.