Brookhaven Health Care Facility, LLC

Based on observations, record review, and interviews the facility did not ensure drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles. This was identified for six (6) (medication carts on Unit A high side, Unit B low and high side, Unit C high side, and Unit D high and low side) of six (6) medication carts reviewed during the Medication Storage Task. Specifically, the medication carts were observed with unidentified loose medication tablets and a hearing screening device stored without a container. The carts were soiled with debris and dried liquid medication residue. The findings are: The Medication/Treatment Labeling and Storage Policy dated 07/2025 documented medications/treatments are stored under proper conditions of sanitation, temperature, light, moisture and ventilation. The policy documented medication/treatment carts are to be kept clean, organized, restocked, and fully equipped. Only drugs/treatments and equipment for preparing and administering drugs/treatments should be stored in a medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility did not ensure that each resident had the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. This was identified for two (2) (Resident #55 and Resident #123) of four (4) residents reviewed for Accident Hazards. Specifically, Resident #55 and Resident #123 were observed on 02/26/2026 and on 02/27/2026 with an inhaler at their bedside. There was no documented evidence that Resident #55 and Resident #123 were assessed by the interdisciplinary team to determine that it was safe for the residents to exercise their right to self-administer. Additionally, there were no physician orders for Resident #55 and Resident #123 to self-administer medications. The findings are:The facility policy titled Self Administration of Medications last revised 11/2021, documented continued approval of the self-administration of medication by the resident is dependent on the resident's compliance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for two (2) (Resident #55 and Resident #171) of ten (10) Residents reviewed for Infection Control. Specifically, 1) Resident #55 had a physician's order for Enhanced Barrier Precautions and Certified Nursing Assistant #1 was observed providing high contact activities such as dressing the resident, transferring the resident to a chair, and then making the resident's bed, without wearing a gown as required ; 2) Licensed Practical Nurse #2 was observed performing a finger stick blood glucose check on Resident #171 and subsequently cleaned the shared glucometer with a 70% alcohol wipe instead of utilizing an antimicrobial disinfectant as per the manufacturer's instructions.The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. This was identified for two (Resident #242 and Resident #293) of two residents reviewed for Choices. Specifically, 1) Resident #242 was observed with the inhalers and nasal spray medications at their bedside during the initial tour and the resident stated they self-administered their inhaler medications. There was no documented evidence that Resident #242 was assessed to self-administer their medications. 2) Resident #293 was observed with the inhalers and a nasal spray medication at their bedside during the initial tour. There was no documented evidence that Resident #293 was assessed to self-administer their medications. The finding is: The facility's Self Administration of Medications policy and procedure last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 11/20/2024 and completed on 11/26/2024 the facility did not ensure each resident received care and services for the provision of parenteral fluids consistent with professional standards of practice, physician orders, and the comprehensive person-centered care plan. This was identified for one (Resident #343) of four residents reviewed for Infection Control. Specifically, Resident #343 was observed on 11/20/2024 with a left arm Midline Intravenous Catheter dressing that was dated 11/01/2024. Additionally, the external Midline catheter length was not measured and recorded as per the physician's orders. The finding is: The facility's policy titled Peripherally Inserted Central Catheter Line/ Midline Care and Treatment last revised on 5/2024, documented that Midline dressing changes are done within 24 hours of new line placement and then every week and as needed. Measure the external catheter length and record the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice. This was identified for one (Resident #84) of one resident reviewed for Respiratory Care. Specifically, Resident #84 had a physician's order to continuously receive oxygen therapy via a nasal cannula at 3 Liters per minute. Resident #84 was observed on 11/20/2024, receiving oxygen therapy via a nasal cannula. The nasal cannula was connected to an oxygen tank which was set to deliver oxygen at 3 liters; however, the oxygen tank gauge needle indicated the tank was empty. The finding is: The facility policy titled Oxygen Therapy last revised on 9/2023, documented apply oxygen per physician's order. The clinical staff is to monitor the oxygen tank gauge during care and at 15-minute intervals and notify the nurse if empty. Nurses are to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure that all residents received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was identified for one (Resident #242) of one resident reviewed for Mood and Behavior. Specifically, Resident #242's hospital records indicated that they experienced suicidal ideation and were placed on a three-day suicide watch before admission to the facility. Direct care staff at the facility were not knowledgeable of the resident's recent history of suicidal ideation and did not develop a person-centered plan of care to address the resident's mental health needs based on the resident's psychosocial history. The finding is: The facility's Behavioral Health Services policy dated 11/2016 documented that each resident will receive, and the facility will provide the necessary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification initiated on 11/20/2024 and completed on 11/26/2024, the facility did not store all drugs and biologicals in secured locked compartments. This was identified for two (Resident #242 and Resident #293) of two residents reviewed for Choices. Specifically, 1) Resident #242 was observed with multiple inhalers and a nasal spray medication at their bedside during the initial tour. There was no nurse observed in the vicinity. 2) Resident #293 was observed with multiple inhalers and a nasal spray medication at their bedside. There was no nurse observed in the vicinity The finding is: The facility's Medication/Treatment Labeling and Storage policy and procedure last revised on 7/2013 documented resident's medications/treatments are to be placed in the proper storage area; medication room, supplies in a clean utility room, treatment cart, or medication cart. Controlled substances are stored in double-locked cabinets in the locked medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification and Abbreviated survey (NY00316297) initiated on 8/16/2023 and completed on 8/23/2023, the facility did not permit a resident to return to the facility after hospitalization and did not ensure there was documented evidence that the Resident's representative was notified of discharge. This was identified for one (Resident #411) of five residents reviewed for discharge (DC). Specifically, Resident # 411 was transferred to the hospital on 5/2/2023 and the facility did not allow the resident to be re-admitted to the facility. Resident # 411 was transferred from the hospital to another Nursing Home. Additionally, there was no documented evidence that Resident #411 or the resident's representative received a notice of discharge/transfer with their appeal rights. The finding is: The Policy and Procedure (P&P) titled Discharge Notice dated 5/2022, documented the facility accepts and retains only those residents that it can provide care for. The policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews during the Recertification Survey initiated on 8/16/2023 and completed on 8/23/2023 the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflect the resident's current status. This was identified for one (Resident # 362) of three residents reviewed for Pressure Ulcers. Specifically, the Nursing admission Skin assessment dated [DATE] documented Right and Left heel Deep Tissue Injuries (DTI). The admission MDS assessment dated [DATE] documented No in section M0210- Unhealed Pressure Ulcer /Injuries. The MDS assessment did not reflect the DTI to the resident's bilateral heels that were noted on the Nursing admission Assessment. The finding is: The facility's, Assessment of Residents policy and procedure updated 2/2020 documented the comprehensive assessment includes at a minimum the resident's skin condition. Review of assessments includes the professional staff shall examine each resident no less than once every 92 days, and as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 8/16/2023 and completed on 8/23/2023, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #21) of three residents reviewed for respiratory care. Specifically, Resident #21 received oxygen treatment continuously for an acute respiratory infection since 4/18/2023. Resident # 21 was seen by the Pulmonologist on 5/24/2023 who recommended a weaning program and discontinuation of supplemental oxygen; however, Resident #21 remained on continuous oxygen with no indication of need. The finding is: The facility Oxygen Therapy policy revised on 8/2018 documented oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. The policy did not address the procedure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 8/16/2023 and completed on 8/23/2023, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments. This was identified for one (Resident #21) of three residents reviewed for respiratory care. Specifically, Resident #21's attending physician did not evaluate the necessity of the resident to have continuous oxygen treatment and did not address the Pulmonologist's recommendation made on 5/24/2023 for weaning the resident off continuous oxygen . The finding is: The facility's Medical Care policy and procedure revised on 7/2015 documented that the attending physician is responsible for the care of the resident at all times. The attending physician is expected to review medications and note resident response to medications and treatments, monitor for continued need for medication and treatments based on the indication, and review consultations. Any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.