Deficiency Records for Lexington Park Nursing and Post Acute Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Lexington Park Nursing and Post Acute Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-26 | 2023-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-28 | 2023-04-30 | N |
| Post nurse staffing information every day. | Health | 2023-03-28 | 2023-04-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-28 | 2023-04-30 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-09 | 2021-12-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-13 | 2021-11-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-13 | 2021-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-13 | 2021-11-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-23 | 2020-01-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-23 | 2020-01-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-23 | 2020-01-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Meet other general requirements. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
