Brookhaven Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff, resident and family interviews and policy review, the facility failed to ensure care conferences were scheduled and conducted quarterly. This affected four (#36, #37, #61 and #85) out of four residents reviewed for care plans. The facility census was 84. Findings include: 1. Medical record review for Resident #36 revealed an admission on [DATE] with diagnosis including but not limited to cerebral atherosclerosis, stage four kidney disease, hypertension. Review of the annual Minimum Data Set for Resident #36 dated 12/29/25 revealed an impaired cognition. Resident #36 was independent for eating, supervision for toileting, transfers and bed mobility. Resident #36 was coded with application of ointments and medication other than to feet. Review of the MDS assessment schedule for Resident #36 revealed quarterly assessments were completed on 10/24/24, 01/21/25, 03/10/25, 05/19/25, 08/13/25, 11/11/25 and an annual on 12/29/25. Review of the plan of care for Resident #36 dated…

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 medical record review, observations, staff interview and policy review, the facility failed to ensure activities were provided and documented in the medical record for evening hours. This affected three (#61, #43, #85) of three residents reviewed for activities. The facility census was 84. Findings include 1. Review of the medical record for Resident #61 revealed an admission on [DATE] with diagnoses including but not limited to Alzheimer's' disease, dementia and psychotic disturbances. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #61 dated 01/27/26 revealed an impaired cognition. Resident #61 was independent for eating. Resident #61 was dependent on staff for toileting, bed mobility and transfers. Review of the plan of care for Resident #61 dated 06/28/24 without revision revealed resident's interest included reading magazines, looking at picture books, being outdoors caring for flowers and televisions game shows. Interventions included activities that do not involve overly…

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 medical record review, staff and Nurse Practitioner (NP) interviews, and facility policy review, the facility failed to monitor and document residents' bowel movements. Additionally, the facility failed to implement their bowel protocol when a resident did not have a bowel movement. This affected one (#93) of three resident reviewed for bowel protocol procedure. The facility census was 84. Findings include: Medical record review for Resident #93 revealed and admission on [DATE] and a discharge date to the hospital on [DATE] with diagnoses including but not limited to type one diabetes, epilepsy, history of myocardial infarction, and neurocognitive disorder with Lewy body (progressive cognitive decline) dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed an impaired cognition. Resident #93 was coded with rejection of care one to three days during the assessment period. Resident #93 required supervision for eating, moderate assistance for bed mobility. Resident…

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 medical record review, observations and staff interviews, the facility failed to ensure foot care was routinely provided for a diabetic resident. This affected one (#85) of three residents reviewed for foot care. The facility census was 84. Findings included: Medical record review for Resident #85 revealed an admission on [DATE] with diagnoses including but not limited to acute and chronic heart failure, type two diabetes and vascular dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed an impaired cognition. Resident #85 was not coded with behaviors or rejection of care. Resident #85 required set up assistance for eating and moderate assistance for toileting bed mobility and transfers. Review of the plan of care for Resident #85 dated 06/21/24 revealed resident had diabetes mellitus and was insulin dependent. Interventions include blood glucose monitoring as ordered, diet as ordered, administer medication as ordered, check all of body for breaks in skin and treat…

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 medical record review, observation, staff interview, and policy review, the facility failed to ensure appropriate urinary catheter care was provided. This affected one (#34) of three residents reviewed for catheter care. The facility census was 84. Findings include: Medical record review for Resident #34 revealed an admission on [DATE] with diagnoses including but not limited to neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 revealed an intact cognition. Resident #34 required set up assistance from staff for eating and dependent on staff for toileting, transfers and bed mobility. Resident #34 was coded for urinary catheter use. Review of the plan of care for Resident #34 revealed resident had a indwelling catheter due to bladder neuromuscular dysfunction. Interventions include catheter care every shift, changing catheter bag as needed and changing catheter per physicians' orders. Observation on 03/03/26 at 4:17 P.M. of…

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 medical record review, observation, staff interviews and policy review, the facility failed to ensure medications were not left at bedside and unsupervised. This affected two (#36 and #37) out of three residents reviewed for medication storage. The facility census was 84. Findings include: 1. Medical record review for Resident #36 revealed an admission on [DATE] with diagnosis including but not limited to cerebral atherosclerosis, stage four kidney disease, hypertension. Review of the annual Minimum Data Set (MDS) for Resident #36 dated 12/29/25 revealed an impaired cognition. Resident #36 was independent for eating, supervision for toileting, transfers and bed mobility. Resident #36 was coded with application of ointments and medication other than to feet. Review of the plan of care for Resident #36 dated 08/23/24 and revised on 08/30/24 revealed resident at risk for skin breakdown or have a known area of skin breakdown. Interventions include administering treatments/medications as ordered, offloading…

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 medical record review, observation, staff interview and policy review, the facility failed to ensure staff followed enhanced barrier precautions as required. This affected one (#34) out of three resident reviewed for infection control. The facility census was 84. Findings include: Medical record review for Resident #34 revealed an admission on [DATE] with diagnoses including but not limited to osteomyelitis of sacral vertebra (spine), peripheral vascular disease and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 revealed an intact cognition. Resident #34 required set up assistance from staff for eating and was dependent on staff for toileting, transfers and bed mobility. Resident #34 was coded for urinary catheter use. Resident #34 was coded as receiving applications of ointment and medications to areas other than the feet during the assessment period. Review of the plan of care for Resident #34 dated 11/18/24 revealed…

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.

Based on observation, record review, and interview, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 91 residents who received meals in the facility. The facility identified Resident #13, #39 and #74 as receiving no food and drink from the kitchen. The facility census was 94. Findings include: Observation on 11/18/24 at 8:58 A.M. and 11/20/24 at 11:19 A.M. revealed a tacky substance on the hoses and a dark substance on the nozzles that connect to juice boxes. Interview on 11/20/24 at 11:19 A.M. with Dietary Director #172 confirmed a tacky substance on the hoses and the presence of a dark substance on the nozzles that connect to the juice boxes. Interview on 11/20/24 at 11:19 A.M. with Corporate Dietician #135 confirmed a tacky substance on the hoses and the presence of a dark substance on the nozzles that connect to the juice boxes. Record review of document titled, Monthly Kitchen Deep Clean, not dated, revealed Dietary and Maintenance will work in combination on a pre-scheduled evening to clean equipment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to timely address concerns with a resident's feeding tube. This affected one (#39) of two residents reviewed for feeding tubes. The census was 94. Findings include: Review of Resident #39's medical record revealed an admission date of 08/23/24. Diagnoses listed included abnormal weight loss, Parkinson's disease, bipolar disorder, dementia, and dysphagia. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severe cognitive impairment, had a feeding tube, and was receiving Hospice services. Review of nursing notes revealed on 11/02/24 at 9:08 P.M. Resident #39's feeding tube was clogged. After unclogging the feeding tube it was noticed that the feeding tube was dark almost black in color and had a foul odor. Feeding tube was flushed repeatedly and a new dressing place. A note was left for physician in the physician communication book. On 11/08/24 at 5:56 A.M., Resident #39's feeding…

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, staff interview, and policy review, the facility failed to administer medications per physician orders. This affected one (Resident #57) of four residents reviewed for medication administration. The facility census was 94. Findings include: Review of the medical record for Resident #57 revealed an admission date of 06/26/24 with diagnoses of malignant neoplasm of right kidney, anemia in chronic kidney disease, and unspecified atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, was independent with eating, required set-up assistance with oral hygiene, required supervision with wheelchair mobility, required partial assistance with bed mobility, and required substantial assistance with toileting hygiene, bathing, and dressing. Review of the Medication Administration Record (MAR) for Resident #57 for November 2024 revealed Potassium Chloride ER Capsule Extended Release (Potassium Chloride) 20 mEq was ordered, but 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.

Based on observation, staff interviews, and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for two residents. This affected two (Residents #75 and #138) of four reviewed for infection control. The facility census was 94. Findings include: 1. Review of the Medical Record for Resident #75 revealed an admission date of 10/02/24 with diagnoses of Parkinsonism, dementia, and neuromuscular dysfunction of the bladder. Review of Resident #75's medical record revealed no documentation for EBP. Observation on 11/18/24 at 3:30 P.M. of Resident #75 revealed the resident had a suprapubic catheter. Observation revealed there were no gowns or gloves available, and there was no sign to advise staff resident was in EBP. Observation on 11/21/24 at 3:00 P.M. revealed Resident #75 with suprapubic catheter to abdomen, with no EBP in place. 2. Review of the Medical Record for Resident #138 revealed an admission date of 10/26/24 with diagnoses of acute kidney failure, end stage renal disease, and dependence on renal dialysis. Review of Resident #138's medical record…

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 medical record review, staff interview, and review of the facility policy, the facility failed to ensure a resident's emergency contact was notified of a fall and a change in condition. This affected one (Resident #3) of three reviewed for notification of changes. The facility census was 91. Findings include: Review of Resident #3's closed medical record revealed an admission date of 01/24/24. Diagnoses included muscle weakness, vascular dementia, heart failure, and pleural effusion. Resident #3 was transferred to a local hospital on [DATE] and did not return to the facility. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10. Review of the progress notes dated 04/06/24 at 3:46 P.M. revealed Resident #3 was found by an State Tested Nursing Assistant (STNA) sitting upright on the floor next to his bed with his wheelchair next to him. The wheelchair was locked and…

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.

Based on observation, record review and interview, the facility failed to store and serve food in accordance with professional standards for food safety. This had the potential to affect 78 residents who received meals in the facility. The facility census was 78. Findings include: Observation of the kitchen on 08/30/21 at 08:28 A.M. revealed a tray of chocolate pudding and vanilla pudding dated 08/23/21. Seven gallons of drinks marked tea, prune juice, and lemonade were not dated. The next cooler contained eight glasses of poured dinks. The drinks were not labeled or dated. Review of the facility food temperature log revealed on 08/02/21, 08/19/21, and 08/20/21 the facility did not record any food temperatures for the meals served on that day. On 08/03/21, 08/04/21, 08/05/21, 08/08/21, 08/09/21, 08/10/21, 08/11/21, 08/12/21, and 08/13/21, the facility did not record any food temperatures of the evening meal. During interview on 08/30/21 at the time of the observations, Registered Dietitian (RD) #500 during the initial tour of the kitchen confirmed the pudding were labeled and dated…

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 medical record review, observation, and staff interview, the facility failed to provide adaptive equipment as ordered. This affected one (Resident #12) of two residents reviewed for use of adaptive equipment. The facility census was 78. Findings include: Review of the medical record for Resident #12 revealed an admission date of 11/30/01. Diagnoses included multiple sclerosis, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance of one staff for eating. Review of the care plan dated 03/10/21 revealed the resident required a divided plate to aid in self-feeding. Review of the nutrition services progress note dated 03/10/21 revealed the resident was able to feed herself at times and a divided plate would be provided with meals. Review of the nutrition services progress note dated 08/26/21…

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.