Inspection Reports for
Brookhaven Care Center
111 Beaverdam Road, Brookhaven, NY, 11719
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Sep 5, 2025
Visit Reason
The abbreviated survey was conducted based on complaint #NY00375947 to investigate concerns related to the use of bed rails and side rail padding for residents.
Complaint Details
Complaint #NY00375947 triggered the abbreviated survey due to concerns about bed rail use and side rail padding. The complaint was substantiated with findings of improper assessment, consent, and use of unsafe padding materials.
Findings
The facility failed to assess residents for risk of entrapment from bed rails prior to installation and did not ensure bed rails were safe. Blankets and pillows were used in place of proper side rail pads for four residents, increasing the risk of entrapment, suffocation, or injury. The Quality Assurance Performance Improvement committee did not address these issues adequately.
Deficiencies (3)
F 0700: The facility did not review risks and benefits of bed rails with residents or representatives and failed to obtain informed consent for four residents. The facility also failed to assess entrapment risks and protect residents from potential harm caused by bed rails.
F 0835: The facility failed to administer resources effectively to ensure safety related to side rail padding. Blankets and pillows were used instead of proper pads on side rails for four residents, increasing entrapment risk.
F 0865: The facility's Quality Assurance Performance Improvement committee did not develop or implement appropriate plans to correct the side rail padding issues identified for four residents, failing to ensure sustained improvements.
Report Facts
Residents reviewed: 27
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #1 | Interviewed regarding use of blankets and pillows as padding and risks of entrapment | |
| Certified Nursing Assistant #4 | Reported use of blankets taped to side rails instead of pads | |
| Certified Nursing Assistant #7 | Reported longstanding use of blankets and pillows in place of pads | |
| Director of Nursing Services | Interviewed about responsibility for ensuring side rail pads and acceptance of blankets/pillows as padding | |
| Administrator | Interviewed about awareness and acceptance of blankets and pillows used as side rail padding and QAPI committee discussions | |
| Assistant Director of Nursing Services | Interviewed about nursing staff responsibilities and views on padding materials | |
| Medical Director | Interviewed about temporary use of blankets and pillows and education status |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with regulatory requirements for Bellhaven Center for Rehab and Nursing Care.
Findings
The facility was found deficient in thoroughly investigating incidents of injury of unknown origin, developing comprehensive person-centered care plans including language barriers, ensuring physician review of residents' total program of care including Medical Orders for Life-Sustaining Treatment, and providing medically-related social services to maintain residents' well-being.
Deficiencies (4)
F 0610: The facility did not thoroughly investigate an injury of unknown origin for Resident #430, failing to identify the root cause and rule out abuse, neglect, or mistreatment.
F 0656: The facility did not develop a comprehensive person-centered care plan for Resident #132 that included measurable objectives and the resident's language barrier.
F 0711: The facility did not ensure that a physician reviewed Resident #132's total program of care, including Medical Orders for Life-Sustaining Treatment, which were inconsistent with physician orders.
F 0745: The facility did not provide medically-related social services to ensure Resident #132's Medical Orders for Life-Sustaining Treatment form was reviewed and consistent with advance directives and physician orders.
Report Facts
Residents reviewed for Accidents: 6
Residents reviewed for hearing and vision: 2
Residents reviewed for Advanced Directives: 2
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with regulatory requirements.
Findings
The facility failed to thoroughly investigate an injury of unknown origin sustained by one resident, failing to identify the root cause and properly document staff observations to rule out abuse, neglect, or mistreatment.
Deficiencies (1)
F 0610: The facility did not ensure all incidents, including an injury of unknown origin, were thoroughly investigated. Staff statements lacked documentation of falls or trauma prior to the injury, and the root cause was not identified to rule out abuse, neglect, or mistreatment.
Report Facts
Residents reviewed for Accidents: 6
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Risk Manager | Interviewed regarding the Accident and Incident Report and staff statements for Resident #430 | |
| Director of Nursing Services | Interviewed about staff statements and facility policy on investigating injuries of unknown origin |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Renewal
Capacity: 60
Deficiencies: 1
Date: Aug 19, 2024
Visit Reason
One violation related to environmental standards (water temperature).
Findings
One violation related to environmental standards (water temperature).
Deficiencies (1)
487.11 (h) (11) — Environmental standards
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: May 16, 2024
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Apr 9, 2024
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 28, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with regulatory requirements and investigate specific incidents involving resident care and safety.
Findings
The facility failed to timely report a resident's right hip fracture to the New York State Department of Health within the required timeframe. Additionally, the facility did not ensure adequate supervision and assistance to prevent accidents, resulting in a resident falling from bed and sustaining bilateral femur fractures due to failure to follow the care plan requiring two-person assistance.
Deficiencies (2)
F 0609: The facility did not report a resident's right hip fracture to the NYSDOH within the required two-hour timeframe after the injury was identified on 1/14/2023, with the report delayed until 1/16/2023.
F 0689: The facility failed to provide adequate supervision and assistance to Resident #82, who required two-person assistance for bed mobility, resulting in a fall from bed and bilateral femur fractures.
Report Facts
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Named in failure to report resident's fracture and incident report initiation |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in reporting fracture to supervisor and physician |
| Registered Nurse #4 | Registered Nurse | Named in failure to initiate incident report and notify DNS |
| RN #5 | Admission Nurse | Named in resident readmission and assessment |
| Physician #1 | Primary Care Physician | Named in diagnosis and interview regarding fracture |
| Director of Nursing Services | Director of Nursing Services (DNS) | Named in interview regarding fracture reporting and care oversight |
| Temporary Nursing Assistant #1 | Temporary Nursing Assistant | Named in incident causing resident fall and injury |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in assisting and witnessing fall incident |
| Registered Nurse #2 | Registered Nurse | Named in responding to fall incident and resident assessment |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in responding to fall incident and reporting |
| RN Inservice Coordinator | RN Inservice Coordinator | Named in staff training and policy education |
| Medical Director | Medical Director | Named in interview regarding resident fall and fracture evaluation |
| Administrator | Administrator | Named in interview regarding staff compliance with care plan |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 28, 2023
Visit Reason
The survey was a Recertification and Abbreviated Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in timely reporting of suspected abuse, ensuring accurate pre-admission PASARR screening, providing adequate supervision to prevent resident falls, ensuring continuous oxygen supply for residents needing respiratory care, and maintaining communication with dialysis centers for residents receiving dialysis.
Deficiencies (5)
F 0609: The facility failed to report a resident's right hip fracture to the New York State Department of Health within the required two-hour timeframe after the injury was identified.
F 0645: The facility did not ensure accurate completion of pre-admission PASARR screening for mental disorders or intellectual disabilities, resulting in incomplete assessment for one resident.
F 0689: The facility failed to provide adequate supervision and assistance to prevent a resident's fall, resulting in bilateral femur fractures due to a staff member not following the two-person assistance care plan.
F 0695: The facility did not ensure continuous oxygen supply for a resident requiring oxygen therapy, as the resident was found with an empty oxygen tank and oxygen saturation of 69%.
F 0698: The facility failed to maintain ongoing communication and collaboration with the dialysis center for a resident receiving dialysis, as the dialysis communication book was lost and not promptly addressed.
Report Facts
Residents reviewed for PASARR: 35
Residents reviewed for Accidents: 4
Residents reviewed for falls: 2
Resident fall risk score: 11
Oxygen saturation: 69
Oxygen saturation after oxygen administration: 94
Dialysis frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Named in failure to report resident's hip fracture and incident report initiation. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in failure to report resident's hip fracture and incident report initiation. |
| Temporary Nursing Assistant #1 | Temporary Nursing Assistant | Named in fall incident causing bilateral femur fractures due to failure to follow two-person assistance plan. |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Named in oxygen tank empty incident and oxygen administration. |
| Registered Nurse #7 | Registered Nurse | Named in missing dialysis communication book incident. |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Named in missing dialysis communication book incident and failure to notify supervisor. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Relicensure
Capacity: 60
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Jan 2, 2023
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 10, 2022
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
487.10 (e) (2) — Records and reports
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: May 11, 2022
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Apr 29, 2022
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 24, 2021
Visit Reason
One violation related to environmental standards (housekeeping).
Findings
One violation related to environmental standards (housekeeping).
Deficiencies (1)
487.11 (j) (1-3) — Environmental standards
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Sep 13, 2021
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 2, 2021
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 21, 2021
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements, including complaint investigation and abbreviated survey components.
Complaint Details
The inspection included an abbreviated complaint investigation (Complaint # NY 00264419) related to staffing and care concerns.
Findings
The facility was found deficient in timely reporting of injuries of unknown origin, thorough investigation of such injuries to rule out abuse, implementation of person-centered care plans for residents with hearing aids, sufficient nursing staff to meet resident needs, and maintaining an effective infection prevention and control program.
Deficiencies (5)
F 0609: The facility did not ensure timely reporting of injuries of unknown origin to the New York State Department of Health as required, identified for Resident #162 with multiple unexplained injuries.
F 0610: The facility failed to thoroughly investigate injuries of unknown origin to rule out abuse, neglect, or mistreatment for Resident #162, lacking pertinent staff and resident interviews.
F 0656: The facility did not implement a complete person-centered care plan with measurable goals for Resident #95 who uses hearing aids, as the resident was observed without the hearing aid on multiple occasions.
F 0725: The facility did not ensure sufficient nursing staff on 3 of 6 nursing units, resulting in extended wait times and difficulty providing timely care to residents.
F 0880: The facility failed to maintain an infection prevention and control program; a wound care nurse did not wash hands and change gloves after cleansing a wound before applying treatment.
Report Facts
Residents: 240
Staffing shortages: 1
BIMS score: 15
BIMS score: 9
Wound size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Supervisor | Registered Nurse Supervisor | Interviewed regarding Resident #162 injury and fall assessment. |
| Director of Nursing Services | Director of Nursing Services (DNS) | Interviewed regarding injury investigations, hearing aid care, and staffing issues. |
| Registered Nurse Risk Manager | Registered Nurse Risk Manager | Interviewed regarding injury investigations for Resident #162. |
| CNA #1 | Certified Nursing Assistant | Interviewed about communication with Resident #95 and hearing aid use. |
| LPN #2 | Licensed Practical Nurse | Interviewed about communication with Resident #95 and hearing aid use. |
| RN #6 | Registered Nurse | Interviewed about communication with Resident #95 and hearing aid use. |
| CNA #4 | Certified Nursing Assistant | Interviewed about staffing shortages on unit A2. |
| CNA #5 | Certified Nursing Assistant | Interviewed about staffing shortages on unit A2. |
| CNA #6 | Certified Nursing Assistant | Interviewed about staffing shortages on unit A1. |
| Administrator | Facility Administrator | Interviewed about staffing shortages and recruitment efforts. |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding wound care procedure deficiencies. |
| RN Wound Care Nurse | Registered Nurse Wound Care Nurse | Observed and interviewed regarding wound care procedure deficiencies. |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control program and wound care practices. |
| RN Inservice Coordinator | Registered Nurse Inservice Coordinator | Interviewed regarding infection control program and wound care practices. |
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