Inspection Report
Follow-Up
Deficiencies: 2
Aug 14, 2025
Visit Reason
The Adult Care Licensure Section and the Davidson County Department of Social Services conducted a follow-up survey on August 12-14, 2025 to verify correction of previous deficiencies.
Findings
The facility failed to ensure that one medication aide (Staff E) had a Clinical Skills Competency Validation Checklist prior to administering medications. Additionally, the facility failed to ensure that one resident (#5) had a physician's order to self-administer medications, and medications were found in the resident's room without proper orders or pharmacy labels.
Deficiencies (2)
| Description |
|---|
| Failed to ensure 1 of 6 medication aides had a Clinical Skills Competency Validation Checklist prior to administering medications. |
| Failed to ensure 1 of 5 sampled residents had a physician's order to self-administer medications; medications found in resident's room without orders or pharmacy labels. |
Report Facts
Medication administration days: 7
Medication administration days: 6
Sampled medication aides: 6
Sampled residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Medication Aide | Named in deficiency for lacking Clinical Skills Competency Validation Checklist |
| Health and Wellness Director | Health and Wellness Director | Responsible for completing Clinical Skills Competency Validation Checklist and self-administration assessments |
| Business Office Manager | Business Office Manager | Responsible for maintaining training documentation and personnel records |
| Executive Director | Executive Director | Interviewed regarding medication aide qualifications and documentation |
| Administrator | Administrator | Interviewed regarding medication self-administration policies and resident medication management |
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 5
May 16, 2025
Visit Reason
Annual survey conducted by the Adult Care Licensure Section from 05/14/25 through 05/16/25 to assess compliance with regulations for a Special Care Unit and Assisted Living facility.
Findings
The facility failed to provide adequate supervision for two residents in the Special Care Unit who eloped, resulting in one resident falling and requiring emergency medical evaluation. Additionally, the facility failed to serve water to most assisted living residents at meals, maintain proper medication orders for vitamin supplements for one resident, and administer medications as ordered for multiple residents. The facility also failed to notify a resident's responsible party within 24 hours of an elopement resulting in injury.
Severity Breakdown
Type A2 Violation: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide supervision according to residents' assessed needs resulting in elopement and injury. | Type A2 Violation |
| Failed to ensure water was served at each meal for 19 of 22 assisted living residents. | — |
| Failed to ensure medication orders were maintained in the resident's record for vitamin supplements for one resident. | — |
| Failed to administer medications as ordered by a licensed practitioner for multiple residents, including delayed antibiotic administration and incorrect medication orders. | Type A2 Violation |
| Failed to notify the responsible party within 24 hours of an elopement resulting in injury for one resident. | — |
Report Facts
Residents present at lunch meal: 22
Residents present at breakfast meal: 22
Medication error rate: 12
Vitamin D3 dosage: 5000
Cephalexin dosage: 500
Amlodipine dosage: 5
Memantine dosage: 10
Donepezil dosage: 10
Quetiapine dosage: 25
Residents sampled: 5
Residents sampled for supervision: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Interviewed regarding supervision failures, medication administration, and notification procedures |
| Health and Wellness Director | Health and Wellness Director (HWD) | Interviewed regarding supervision failures, medication administration, and notification procedures |
| Administrator | Interim Administrator | Interviewed regarding supervision failures, medication administration, and notification procedures |
| Medication Aide | Medication Aide (MA) | Multiple interviews regarding medication administration errors and supervision failures |
| Personal Care Aide | Personal Care Aide (PCA) | Interviewed regarding supervision failures and resident observations |
| Sales Manager | Sales Manager | Interviewed regarding elopement incident and resident supervision |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 27, 2024
Visit Reason
Report of a Construction Section Biennial Follow Up Survey conducted on March 27, 2024.
Findings
Corrections have been made. No further action is necessary.
Inspection Report
Annual Inspection
Deficiencies: 7
Feb 22, 2024
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 02/21/24 to 02/22/24 to assess compliance with regulations and verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including medication staff qualifications, training on care of diabetic residents, supervision of residents related to falls, health care referral and follow-up, medication order clarification, medication administration, and medication disposition. Several residents had missing training documentation, inadequate supervision leading to multiple falls with injuries, failure to follow medication orders correctly, and expired medications administered.
Severity Breakdown
Type B Violation: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 6 sampled medication aides had completed required medication aide training. | — |
| Facility failed to ensure 5 of 6 sampled medication aides had completed training on care of diabetic residents prior to administering insulin. | — |
| Facility failed to ensure supervision for 3 of 5 sampled residents related to multiple falls resulting in injuries and lacked post-fall evaluations and analyses. | Type B Violation |
| Facility failed to ensure health care referral and follow-up for 1 of 5 sampled residents related to hearing aid management and weekly weight orders. | — |
| Facility failed to clarify medication orders for 1 of 5 sampled residents for vitamin supplements and homeopathic treatments without physician orders. | — |
| Facility failed to administer medications as ordered for 2 of 5 sampled residents who had sliding scale insulin and long-acting insulin orders. | — |
| Facility failed to ensure expired medication was destroyed or returned to pharmacy within 90 days for 1 of 5 sampled residents. | — |
Report Facts
Medication administration discrepancy: 9
Missed medication doses: 5
Falls: 9
Falls: 6
Falls: 4
Medication quantity: 100
Medication quantity: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Aide | Named in deficiency for missing medication aide training and diabetic care training. |
| Business Office Manager | Interviewed regarding missing training documentation and personnel record audits. | |
| Administrator | Interviewed regarding oversight of training, medication administration, and fall interventions. | |
| Area Nurse Manager | Interviewed regarding fall management policy and post-fall evaluations. | |
| Resident Care Coordinator | Interviewed regarding fall interventions and medication order management. | |
| Special Care Unit Coordinator | Interviewed regarding fall interventions and hearing aid management. | |
| Medication Aide | Multiple medication aides interviewed regarding medication administration, hearing aid management, and vitamin supplements. |
Inspection Report
Follow-Up
Deficiencies: 3
Jan 12, 2024
Visit Reason
The report documents a Biennial Follow Up Construction Survey conducted to verify correction of previously cited deficiencies related to building and fire safety at Brookdale Lexington.
Findings
The survey found ongoing deficiencies including incomplete fire safety rehearsal logs lacking descriptions, failure to maintain fire safety equipment such as doors that do not close and latch properly, and non-functioning exhaust ventilation in specified areas.
Deficiencies (3)
| Description |
|---|
| Fire rehearsal logs did not include a short description of what the rehearsal involved. |
| Failure to maintain fire safety equipment; doors in Employee Breakroom and Room 407 do not close and latch properly. |
| Exhaust ventilation not maintained; exhaust fan in 400 Hall Hopper Room is not working. |
Inspection Report
Annual Inspection
Deficiencies: 3
Sep 23, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up and annual survey from 09/21/22 to 09/23/22 to assess compliance with medication administration regulations.
Findings
The facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents. Resident #1 did not receive vitamin B12 daily as ordered and estrace vaginal cream was inconsistently administered due to staff refusal. Resident #3's medication tamsulosin was administered every other day instead of daily as ordered, with no clarification from the PCP.
Deficiencies (3)
| Description |
|---|
| Failure to administer vitamin B12 as ordered daily for Resident #1. |
| Failure to administer estrace vaginal cream as ordered for Resident #1, with staff refusal to apply the medication and lack of PCP notification. |
| Failure to administer tamsulosin daily as ordered for Resident #3; medication was given every other day without PCP clarification. |
Report Facts
Missed estrace cream doses: 15
Tamsulosin administration days: 15
Tamsulosin administration days: 16
Tamsulosin administration days: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Refused to administer estrace vaginal cream to Resident #1 due to discomfort with resident's comments. | |
| Resident Care Coordinator | Responsible for reviewing medication orders and was aware of medication administration issues but did not notify PCP. | |
| Administrator | Expected medications to be administered as ordered and acknowledged responsibility for oversight. | |
| Primary Care Provider | Signed medication orders but did not clarify conflicting orders or was not notified of administration issues. |
Inspection Report
Follow-Up
Deficiencies: 1
Jan 8, 2020
Visit Reason
The Adult Care Licensure Section and Davidson County Department of Social Services conducted a follow-up survey on 01/07/19 through 01/08/19 to verify correction of previous deficiencies.
Findings
The facility failed to ensure that one of five sampled staff (Staff A) had no substantiated findings listed on the North Carolina Health Care Personnel Registry upon hire, as required. Documentation showed a Health Care Personnel Registry (HCPR) check was not completed upon Staff A's rehire date.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure 1 of 5 sampled staff (Staff A) had no substantiated findings listed on the North Carolina Health Care Personnel Registry upon hire. |
Report Facts
Number of sampled staff: 5
Hire date of Staff A: Nov 6, 2018
Date of HCPR check documentation: Jul 28, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Named in deficiency for lack of HCPR check upon rehire |
| Business Office Manager | Responsible for ensuring HCPR checks, admitted fault for missing check on Staff A | |
| Administrator | Interviewed regarding responsibility and awareness of HCPR check requirements |
Inspection Report
Annual Inspection
Census: 5
Deficiencies: 5
Sep 16, 2019
Visit Reason
Annual survey conducted from 09/12/19 through 09/13/19 and on 09/16/19 to assess compliance with state regulations for adult care homes.
Findings
The facility failed to assure exit doors were properly alarmed for a resident with dementia exhibiting exit-seeking behaviors, failed to provide adequate supervision for residents with exit-seeking behaviors and repeated falls, and failed to administer medications as ordered, including antibiotics for a resident with infection.
Severity Breakdown
Type B Violation: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to assure 1 of 3 exit doors accessible for residents had an alarm that activated for safety for a resident with dementia who eloped without staff knowledge. | Type B Violation |
| Failed to provide supervision for 3 of 5 sampled residents who exhibited exit-seeking behaviors and eloped or had repeated falls resulting in injuries. | Type B Violation |
| Failed to ensure medications were administered as ordered for 1 resident related to antibiotic medications. | Type B Violation |
| Failed to assure 3 of 6 Medication Aides had completed mandatory annual infection control training. | — |
| Failed to ensure residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to physical environment, personal care and supervision, and medication administration. | — |
Report Facts
Fingerstick blood sugar range: 363
Fingerstick blood sugar range: 326
Medication order duration: 7
Medication order duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide/Supervisor | Named in infection control training deficiency and medication administration findings. |
| Staff C | Medication Aide/Supervisor | Named in infection control training deficiency. |
| Staff E | Medication Aide | Named in infection control training deficiency. |
| Health and Wellness Director | Named in supervision, medication administration, and infection control training findings. | |
| Executive Director | Named in supervision, medication administration, and infection control training findings. | |
| Business Office Coordinator | Named in supervision and medication administration findings. |
Inspection Report
Follow-Up
Deficiencies: 1
Apr 18, 2018
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies.
Findings
Some deficiencies were not corrected, specifically the interior doors were not maintained in a safe and operating condition. The corridor door's replacement hardware in Azalea Hall Laundry did not cover previous holes and the latchset strike was missing.
Deficiencies (1)
| Description |
|---|
| Interior doors not maintained in a safe and operating condition; corridor door's replacement hardware did not cover two through holes and latchset strike is missing. |
Inspection Report
Capacity: 76
Deficiencies: 14
Jan 24, 2018
Visit Reason
Construction Section Biennial Survey conducted to assess compliance with applicable physical plant, fire safety, and building code requirements.
Findings
Multiple deficiencies were identified including failure to meet delayed egress locking system requirements, lack of fire-resistance rated assemblies, missing current fire safety inspection reports, inadequate hand grips in tubs, poor housekeeping and maintenance issues, incomplete fire safety rehearsals, unsafe building equipment and fire safety conditions, and inadequate exhaust ventilation in certain storage areas.
Deficiencies (14)
| Description |
|---|
| Delayed Egress Locking System did not initiate irreversible release with force greater than 15 pounds for more than three seconds at exit near Bedroom 403. |
| SCU Cross-Corridor Door between Courtyard and Activity is not a fire-resistance rated assembly. |
| Facility failed to maintain current (within last 12 months) annual Fire Marshal Inspection Report; last was December 19, 2016. |
| Tubs accessible to residents lacked hand grips; specifically, spa near room 310 had no grab bar. |
| Building mechanical systems not kept clean; ventilation grilles with excessive dust/lint in multiple locations. |
| Ice machine drain piped directly onto floor drain risking contamination due to backflow. |
| Facility not maintained orderly and free of obstructions; garden hose draped across stoop near Bedroom 210 creating tripping hazard. |
| Fire drill rehearsals not performed regularly on all shifts quarterly; missing rehearsals on 3rd shift in 1st and 3rd quarters, and 2nd shift in 4th quarter; records incomplete. |
| Building fire safety not maintained; multiple fire-resistance rated ceiling and wall assemblies damaged or altered, missing escutcheon plates on sprinkler heads allowing smoke and heat spread. |
| Emergency exit signs and emergency lights failed to illuminate on backup power or had incorrect directional indicators. |
| Interior corridor doors not smoke tight, had gaps, did not latch properly, or had hardware issues affecting fire/smoke containment. |
| Egress from some areas required keys or special knowledge; walk-in refrigerator/freezer locked with padlock and no override device. |
| Commercial kitchen hood fire suppression system lacked required inspections and maintenance documentation; last maintained May 2017. |
| Facility failed to provide exhaust ventilation in storage rooms near Bedrooms 107 and 108 where odors and chemicals were present. |
Report Facts
Total licensed capacity: 76
Date of last Fire Marshal Inspection Report: Dec 19, 2016
Date of inspection: Jan 24, 2018
Date of last kitchen hood fire suppression maintenance: 201705
Inspection Report
Annual Inspection
Deficiencies: 2
Dec 22, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale Lexington on 12/20/16 through 12/22/16 to assess compliance with state regulations regarding resident care and facility operations.
Findings
The facility failed to provide adequate supervision for Resident #1, who had frequent falls resulting in serious injuries including a fractured pelvis and head injury. Additionally, the facility failed to maintain an accurate medication administration record for Resident #6, with discrepancies in lisinopril dosage documented and administered. These deficiencies indicate lapses in resident care and medication management.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide supervision for Resident #1 with frequent falls resulting in injuries including fractured pelvis, head injury, broken toe, and arm injury. | Type A1 Violation |
| Failure to ensure accuracy of Medication Administration Record for Resident #6, with incorrect lisinopril dosage documented and administered. | — |
Report Facts
Number of falls: 18
Correction deadline: 2017
Blood pressure range: Resident #6's blood pressures ranged from 128/68 to 146/92 from July to December 2016.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Reported Resident #1's fall and described supervision practices. | |
| Health and Wellness Director | Responsible for reviewing incident reports and implementing interventions. | |
| Resident Care Coordinator | Responsible for ensuring care plans were updated and compliance with facility policy. | |
| Physician's Assistant | Confirmed orders and discussed Resident #1's fall risk. | |
| District Director of Clinical Services | Discussed incident report trends and interventions. | |
| Executive Director | Oversaw fall prevention efforts and facility policies. | |
| Administrator | Unaware of medication discrepancy and expected staff to identify it. |
Inspection Report
Follow-Up
Deficiencies: 3
Mar 28, 2016
Visit Reason
This report is of a follow-up survey conducted to verify correction of previously identified deficiencies at Brookdale Lexington.
Findings
The follow-up survey revealed that several deficiencies related to building equipment maintenance and fire safety were not corrected, including non-working battery-powered emergency lights, corridor doors not fitting properly to resist fire and smoke, and an exit sign not working on battery back-up.
Deficiencies (3)
| Description |
|---|
| Several battery powered emergency lights would not work when tested, including in the accounting office. |
| Corridor doors are prevented from closing quickly or are not latching or fitting well enough to resist the passage of fire and smoke, including the laundry door on the 300 Hall. |
| An exit sign in the dining room would not work on battery back-up. |
Inspection Report
Routine
Capacity: 76
Deficiencies: 16
Feb 2, 2016
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1996 Homes for the Aged and Disabled Minimum Standards and Regulations, 2005 Rules for Adult Care Homes for Seven or More Beds, and the 1996 North Carolina State Building Code.
Findings
Multiple deficiencies were identified including loosely mounted hand grips in bathrooms, irregular fire safety rehearsals, incomplete and damaged fire alarm system due to lightning strike, malfunctioning delayed egress and smoke barrier doors, non-working emergency lights, compromised fire rated walls and ceilings, improperly closing corridor doors, malfunctioning magnetic lock on courtyard gate, non-working exit sign battery backup, obstructed sprinkler heads, unsafe handling of portable oxygen cylinders, fallen gable end vent allowing pest entry, unlocked range in community center, and non-functioning exhaust ventilation in several areas.
Deficiencies (16)
| Description |
|---|
| Hand grips at shower and toilet in spa on 300 Hall loosely mounted. |
| Fire drill rehearsals not done regularly on all shifts each quarter. |
| Incomplete and damaged fire alarm system due to lightning strike on 12-24-2015. |
| Delayed egress doors did not unlock or open properly upon fire alarm activation. |
| Smoke barrier doors did not close upon fire alarm activation. |
| Several battery powered emergency lights failed to work when tested. |
| One-hour fire rated walls and ceilings compromised with unsealed penetrations and holes. |
| Corridor doors wedged open or not latching properly, including storage/electrical panel room and bedrooms. |
| Special Care courtyard gate magnetic lock malfunctioning due to sagging gate. |
| Exit sign in dining room not working on battery backup. |
| Several sprinkler heads in attic covered with insulation. |
| Barrel bolt latch on mechanical room door corrected during survey. |
| Portable medical oxygen cylinder stored improperly without rack or container in room 102. |
| Gable end vent fallen out over kitchen allowing pest entry. |
| Range in Community Center not locked in off position and unattended by staff. |
| Exhaust ventilation not working in AL laundry, AL janitor closet, and public bathroom. |
Report Facts
Total licensed capacity: 76
Date of lightning strike: Dec 24, 2015
Fire alarm repair deadline: Feb 12, 2016
Delayed egress door repair deadline: Feb 12, 2016
Inspection Report
Annual Inspection
Census: 22
Capacity: 24
Deficiencies: 4
Nov 13, 2014
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on 11/13/14 with an exit conference via phone on 11/21/14. The complaint investigation was initiated on 11/14/14.
Findings
The facility failed to maintain hot water temperatures within the required range of 100 to 116 degrees Fahrenheit at multiple fixtures in both assisted living and the Special Care Unit. Additionally, the facility failed to ensure tuberculosis testing compliance for some staff and did not have proper physician orders or care plans for the use of a PVC Ambulatory Walker restraint on a resident.
Complaint Details
Complaint investigation was initiated on 11/14/14 related to hot water temperature issues.
Severity Breakdown
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Hot water temperatures for 5 of 5 sampled fixtures in assisted living and 2 of 7 in the Special Care Unit were not maintained between 100°F and 116°F. | Type B Violation |
| Facility failed to assure 3 of 6 staff were tested upon employment for tuberculosis disease in compliance with control measures. | — |
| Physical restraint (PVC Ambulatory Walker) used without a written physician order and without assessment and care planning for 1 sampled resident. | — |
| Facility failed to assure residents received care and services which are adequate, appropriate, and in compliance with relevant laws and regulations related to hot water temperatures. | — |
Report Facts
Licensed beds: 24
Residents present: 22
Hot water temperature readings: 128
Hot water temperature readings: 118
Hot water temperature readings: 124
Hot water temperature readings: 126
Number of TB tests missing second test: 3
Duration of elevated hot water issue: 2
Resident observation duration: 120
Wet spot diameter: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Technician | Checked water temperatures, called plumber multiple times regarding elevated hot water temperatures | |
| Administrator | Aware of hot water temperature issues and plumbing repairs; responsible for staff instructions and signage | |
| Plumber | Made three visits to adjust hot water temperatures and repaired mixing valve | |
| Health and Wellness Director | Reported elevated hot water temperatures and participated in staff meetings about safety | |
| Personal Care Assistant (PCA) | Aware of elevated hot water temperatures and resident refusals of showers | |
| Resident Assistant | Provided care to Resident #2 using PVC Ambulatory Walker | |
| Medication Aide | Provided care to Resident #2 and reported fall incident in walker | |
| Memory Care Coordinator | Oversaw care of Resident #2 and use of PVC Ambulatory Walker | |
| Resident Care Director | Involved in decision to use PVC Ambulatory Walker for Resident #2 | |
| Business Office Manager | Responsible for sending staff for TB testing | |
| Health and Wellness Coordinator (HWC) | Responsible for TB testing compliance | |
| Staff B | Medication Aide | Missing second TB skin test upon employment |
| Staff E | Resident Assistant | Missing second TB skin test upon employment |
| Staff F | Medication Aide | Missing second TB skin test upon employment |
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