Inspection Reports for Brookhaven Center for Rehabilitation and Healthcare
NJ
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Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and NJDHSS's legal duties and procedures for changes to the notice.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 122
Deficiencies: 10
Mar 7, 2024
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions on behalf of the New Jersey Department of Health due to multiple complaints.
Findings
The facility was found not in substantial compliance with requirements for long term care facilities. Deficiencies included failure to develop and implement comprehensive, resident-centered care plans, failure to ensure interdisciplinary team participation in care planning, failure to follow physician orders for treatment and restorative nursing, failure to properly assess residents before and after nebulizer medication, failure to maintain bedrails properly, and infection control deficiencies related to storage of nebulizer masks.
Complaint Details
The visit was triggered by multiple complaints with complaint numbers NJ153393, NJ153491, NJ155983, NJ156842, NJ156879, NJ157907, NJ1602145, NJ160748, NJ162328, and NJ163468.
Severity Breakdown
SS=D: 6
SS=E: 1
SS=F: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure one of eight residents reviewed had a comprehensive, resident-centered care plan for side rails use. | SS=D |
| Failed to ensure interdisciplinary team participation in care plan meetings for eight residents. | SS=E |
| Failed to follow physician orders for one resident regarding application of prescribed treatment. | SS=D |
| Failed to follow physician orders for restorative nursing and range of motion exercises for one resident. | SS=D |
| Failed to ensure respiratory care including oxygen and nebulizer medication administration and assessment per physician orders for two residents. | SS=D |
| Failed to ensure proper assessment and storage of nebulizer masks for one resident. | SS=D |
| Failed to maintain vertical openings with proper fire exit hardware on first-floor stairway door. | SS=F |
| Failed to perform smoke detection sensitivity testing every alternate year as required. | SS=F |
| Failed to recalibrate or replace sprinkler system pressure gauges every five years as required. | SS=F |
| Failed to maintain required minimum direct care staff-to-resident ratios on multiple day shifts over several years. | — |
Report Facts
Survey Census: 112
Total Capacity: 122
Deficient CNA staffing days: 41
Sample Size: 27
Inspection Report
Life Safety
Census: 110
Capacity: 122
Deficiencies: 3
Mar 6, 2024
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health on 03/06/24 to assess compliance with fire safety regulations and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including improper hardware on a first-floor stairway fire door, lack of smoke detector sensitivity testing, and failure to recalibrate sprinkler system pressure gauges. These deficiencies had the potential to affect all 110 residents.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| The first-floor stairway door (#1) was equipped with panic hardware instead of the required fire exit hardware, compromising the fire resistance rating of the door. | SS=F |
| The facility failed to ensure smoke detection sensitivity testing of the smoke detectors was completed every alternate year as required. | SS=F |
| The sprinkler system pressure gauges were not recalibrated or replaced every five years and lacked date labels indicating calibration or replacement. | SS=F |
Report Facts
Current occupied beds: 110
Total licensed capacity: 122
Deficiency completion dates: K311 correction due 4/29/24, K345 correction due 5/15/24, K353 correction due 4/29/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified door hardware deficiency and confirmed lack of smoke detector sensitivity testing and sprinkler gauge recalibration |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 1
Jan 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ00170694) to determine compliance with staffing requirements and other regulatory standards.
Findings
The facility was found not in compliance with New Jersey staffing ratio requirements for 7 of 14 day shifts during the weeks of 1/14/24 to 1/27/24, failing to meet the minimum number of Certified Nurse Aides (CNAs) required. No negative outcomes to residents were reported during these shifts.
Complaint Details
Complaint #: NJ00170694. The complaint was substantiated by findings that the facility did not meet minimum staffing ratios on multiple day shifts. The facility was required to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 7 of 14 day shifts. |
Report Facts
Census: 117
Sample Size: 7
Days with insufficient CNAs: 7
Required CNAs per day shift: 14
Actual CNAs on specific days: 10
Actual CNAs on specific days: 13
Actual CNAs on specific days: 12
Actual CNAs on specific days: 13
Actual CNAs on specific days: 13
Actual CNAs on specific days: 12
Actual CNAs on specific days: 12
Inspection Report
Abbreviated Survey
Census: 111
Deficiencies: 1
Nov 1, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CMS/CDC recommended practices for COVID-19 preparation.
Findings
The facility failed to follow appropriate infection control practices related to doffing PPE and disinfecting equipment after resident use, specifically by one nursing staff member observed not sanitizing equipment or properly doffing PPE, risking transmission of infection.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow appropriate infection control practices for doffing PPE and disinfecting equipment after resident use, risking transmission of infection. | SS=D |
Report Facts
Sample size: 13
Residents positive for COVID-19: 3
Residents on PUI (Person Under Investigation): 11
Residents reviewed: 2
Completion date of plan of correction: Dec 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed failing to properly doff PPE and sanitize equipment | |
| Director of Nursing (DON) | Confirmed PPE requirements and commented on infection control deficiencies | |
| Infection Preventionist Nurse (IPN) | Observed LPN's improper PPE use and addressed the issue |
Inspection Report
Plan of Correction
Census: 116
Deficiencies: 1
Dec 9, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on staffing ratios as per new minimum staffing requirements.
Findings
The facility was found not in compliance due to failure to meet required staffing ratios on 3 of 14 day shifts reviewed, with fewer Certified Nurse Aides (CNAs) than required for the resident census. The facility submitted a plan of correction detailing corrective actions to address staffing deficiencies.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met for 3 of 14 day shifts, with fewer CNAs than required by state law. |
Report Facts
Day shifts reviewed: 14
Total shifts reviewed: 42
Residents on day shifts: 116
CNAs on 11/14/21: 13
CNAs on 11/20/21: 14
CNAs on 11/21/21: 14
Inspection Report
Life Safety
Capacity: 122
Deficiencies: 2
Dec 7, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/07/2021 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found noncompliant with emergency lighting requirements and corridor door smoke resistance. Specifically, emergency lighting was missing above the emergency generator transfer switch, and 4 of 60 resident room doors did not close and latch properly, potentially compromising fire and smoke containment.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide battery backup emergency lighting above the emergency generator's transfer switch independent of the building's electrical system and emergency generator. | SS=D |
| Corridor doors (resident room doors) failed to close properly and latch, restricting the ability to confine fire and smoke products. | SS=D |
Report Facts
Certified beds: 122
Resident room doors with deficiencies: 4
Resident rooms observed: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified emergency lighting deficiency and door latch issues | |
| Regional Plant Operations Director | Verified emergency lighting deficiency and door latch issues | |
| Administrator | Notified of findings at Life Safety Code exit conference |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 3
Nov 4, 2021
Visit Reason
The inspection was conducted based on complaint surveys NJ149514, NJ144485, and NJ146745 to assess compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found non-compliant in providing residents with meals that met their dietary preferences and meal ticket accuracy, infection prevention and control practices especially related to PPE use on the PUI unit, and maintaining clean and sanitized resident room bathrooms on the floor.
Complaint Details
The visit was complaint-driven based on complaints NJ149514, NJ144485, and NJ146745. The facility was found not in compliance with requirements based on these complaints.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents received the food on the meal ticket and adhered to resident preferences affecting 3 residents. | SS=E |
| Failure to ensure a certified nursing assistant donned proper PPE prior to entering a resident room on the PUI unit during the COVID-19 pandemic. | SS=E |
| Failure to maintain resident room bathrooms on the floor as clean and sanitized, affecting 8 out of 22 rooms observed. | SS=E |
Report Facts
Census: 117
Sample Size: 6
Deficiency Completion Date: Dec 17, 2021
Deficiency Completion Date: Dec 24, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Observed not wearing proper PPE on the PUI unit and re-educated on infection control standards. |
| Assistant Director of Nursing | ADON | Observed CNA #1 not wearing PPE and confirmed facility expectations for PPE use on the PUI unit. |
| Director of Nursing | DON | Reviewed counseling and in-servicing completed with CNA #1 following observations. |
| Food and Beverage Director | FBD | Interviewed regarding meal ticket accuracy and tray line procedures. |
| Registered Dietician | RD | Interviewed about complaints regarding tray ticket accuracy and double portion concerns. |
| Regional Registered Dietician | RRD | Interviewed about kitchen staff and efforts to improve tray accuracy. |
| Licensed Practical Nurse #1 | LPN | Interviewed about bathroom cleanliness and observed multiple deficiencies. |
| Housekeeping Director | HD | Interviewed about bathroom cleanliness and housekeeping rounds. |
| Nursing Home Administrator | NHA | Interviewed about performance improvement plan related to housekeeping. |
Inspection Report
Routine
Census: 103
Deficiencies: 0
Jan 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 11
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