Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookhaven At Lexington during CMS and state inspections, most recent first.
A facility failed to follow a physician's order to obtain an apical pulse before administering Digoxin to a resident with severe cognitive impairment and heart conditions. Instead, a nurse used a pulse oximeter to measure the heart rate, which was not in compliance with the order. The DON confirmed that an apical pulse was only required if specified in the order.
A resident with heart failure and atrial fibrillation was given Digoxin without the required apical pulse check. Instead, a nurse used a pulse oximeter, which is against the professional standard outlined in the drug guide. Both the nurse and the DON misunderstood the requirement, believing an apical pulse was only necessary if specified by the physician.
A surveyor observed a nurse leaving medications unsecured on a medication cart during a medication pass. The nurse left a Lisinopril pill and a Carbamazepine tablet unattended while administering other medications to a resident. The nurse admitted to forgetting to administer the medications earlier, and the DON confirmed that medications should not be left unsecured.
Failure to Follow Physician's Order for Apical Pulse Measurement
Penalty
Summary
The facility failed to adhere to a physician's order for a resident with severe cognitive impairment and multiple active diagnoses, including heart failure and atrial fibrillation. The physician's order specified that an apical pulse should be obtained before administering Digoxin, a heart medication, and that the medication should be withheld if the apical pulse was less than 60 beats per minute. However, during a medication pass, a nurse used a pulse oximeter to measure the resident's heart rate, which read 93 beats per minute, and proceeded to administer the Digoxin without obtaining the required apical pulse. The nurse stated that she typically used a pulse oximeter to measure the resident's pulse before administering Digoxin and would only obtain an apical pulse if explicitly required by the physician's order. The Director of Nurses confirmed that obtaining an apical pulse was only necessary if specified in the physician's order, and otherwise, a pulse oximeter or wrist heart rate measurement was deemed acceptable. This practice led to the facility's failure to comply with the specific physician's order for the resident in question.
Failure to Monitor Apical Pulse Before Administering Digoxin
Penalty
Summary
The facility failed to adhere to professional standards for monitoring heart rate by apical pulse before administering the heart medication Digoxin to a resident. The resident, who has a history of heart failure, atrial fibrillation, seizures, and stroke, was observed during a medication pass where Nurse #1 used a pulse oximeter to measure the resident's heart rate instead of obtaining an apical pulse as required by the physician's order. The pulse oximeter showed a heart rate of 93 beats per minute, and the medication was administered without verifying the apical pulse. During interviews, Nurse #1 and the Director of Nurses (DON) both indicated a misunderstanding of the standard practice for administering Digoxin. Nurse #1 stated that she typically uses a pulse oximeter unless the physician's order specifies an apical pulse, while the DON confirmed that an apical pulse is only required if explicitly ordered by the physician. This practice contradicts the professional standard outlined in the [NAME] Drug Guide, which mandates monitoring the apical pulse for one full minute before administering Digoxin and holding the dose if the pulse rate is less than 60 beats per minute.
Failure to Secure Medications During Medication Pass
Penalty
Summary
The facility failed to secure medications during a medication pass, as observed by a surveyor. On the morning of October 22, 2024, Nurse #1 was observed leaving a small pink pill, identified as Lisinopril, unattended on top of the medication cart. This occurred between 9:51 A.M. and 10:11 A.M. while Nurse #1 was administering medications in a resident's bedroom. Additionally, Nurse #1 was seen placing a tablet of Carbamazepine into a medication cup on the cart and leaving it unsecured while attending to a resident in their room for approximately eight minutes. During an interview, Nurse #1 acknowledged that the medications should not have been left unsecured and admitted to forgetting to administer them earlier. The Director of Nurses confirmed that it is expected for nursing staff to supervise any medications left on the cart. The incident highlights a lapse in following the facility's protocol for securing medications, as medications were left unattended and unsecured on the medication cart during the medication pass.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Knoll Nursing Center | 1.3 mi | — | 47 | 1 |
| Meadow Green Nursing And Rehabilitation Center | 2.3 mi | ★★★★★ | 17 | 0 |
| Care One At Lexington | 2.6 mi | ★★★★★ | 11 | 0 |
| Belmont Manor Nursing Home, In | 2.7 mi | ★★★★★ | 13 | 0 |
| Maristhill Nursing & Rehabilitation Center | 2.8 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.