Cycle 1
Health 2025-11-24 · Fire 2025-11-24
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lexington, MA
Brookhaven At Lexington
5-star overall rating with 5-star inspections with 7 fire-safety deficiencies in the latest cycle
1010 Waltham Street, Lexington, MA
(781) 863-9660
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
10
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-01-09
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 2.44% · Lower 95% interval 5.89% |
| Discharge to community | 65.72% |
50.57%
15.1 pts better
|
Better than the National Rate · Eligible stays 39 · Observed rate 71.79% · Lower 95% interval 53.65% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 93.55% |
95.27%
1.7 pts worse
|
Numerator 29 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 31.03% |
53.69%
22.7 pts worse
|
Numerator 9 · Denominator 29 |
| Discharge mobility score | 37.93% |
50.94%
13 pts worse
|
Numerator 11 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.43% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 0% · Lower 95% interval 2.44% |
| Staff COVID-19 vaccination coverage | 16.07% |
8.2%
7.9 pts better
|
Numerator 9 · Denominator 56 |
| Staff flu vaccination coverage | 48.57% |
42%
6.6 pts better
|
Numerator 34 · Denominator 70 |
| Discharge function score | 55.17% |
56.45%
1.3 pts worse
|
Numerator 16 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 100% |
25.2%
74.8 pts better
|
Numerator 21 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.2%
7.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 15.4% |
3.5%
11.9 pts worse
|
3.3%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.2%
5.2 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.3% |
19.2%
14.9 pts better
|
19.6%
15.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.3% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
21.7%
6.3 pts better
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.6%
0.3 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
77.1%
21.8 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.2% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.7% |
11.8%
8.1 pts better
|
12.0%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.7% · Observed 2.9% · Expected 8.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
77.7%
18.1 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.2% |
25.8%
18.6 pts better
|
23.9%
16.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 5.9% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-22 · Fire 2024-10-22
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-10-11 · Fire 2023-10-11
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-12-30
F · Potential for more than minimal harm
2025-11-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-11-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-17
F · Potential for more than minimal harm
2025-11-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-30
F · Potential for more than minimal harm
2025-11-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-30
F · Potential for more than minimal harm
2025-11-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2026-01-30
F · Potential for more than minimal harm
2025-11-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-16
F · Potential for more than minimal harm
2024-10-22
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-10-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-10-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-10-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-23
D · Potential for more than minimal harm
2024-10-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-23
D · Potential for more than minimal harm
2024-10-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-23
D · Potential for more than minimal harm
2023-10-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-13
Penalties and ownership
What sits behind the stars
Ownership
Cohen, Robert
Corporate Officer · Individual
Dunham, Ralph
Corporate Officer · Individual
Finn, Erin
Corporate Director · Individual
Finn, Erin
W-2 Managing Employee · Individual
Freehling, James
Corporate Director · Individual
Freehling, James
Corporate Officer · Individual
Freehling, James
W-2 Managing Employee · Individual
Kirpatrick, Susanna
Corporate Director · Individual
Kirpatrick, Susanna
W-2 Managing Employee · Individual
Mcnamara, Pamela
Corporate Officer · Individual
Schwartz, Eric
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Pine Knoll Nursing Center
Lexington, MA
0-star overall rating with 0-star inspections with Special Focus status with $241,047 in total fines with 14 recent health deficiencies
#2
Meadow Green Nursing And Rehabilitation Center
Waltham, MA
1-star overall rating with 1-star inspections with $195,559 in total fines with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Care One At Lexington
Lexington, MA
2-star overall rating with 2-star inspections with $51,765 in total fines with 22 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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