Brookhaven Health Care Center

In the surveyor’s words

From the most serious findings on record at Brookhaven Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 25, 2025

  Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 08/19/2025 from 09:33 AM until 10:09 AM, the surveyor observed the following in the kitchen in the presence of the Director of Dietary (DD): 1.In the freezer #1 a large block of pepper jack cheese was wrapped in clear plastic with no label and no date. The DD said that the staff cut a smaller piece off the cheese and labeled the smaller piece but not the large block. She stated the cheese should have been labeled and dated. 2. […]

• No harm, potential for more than minimal, patternF761Aug 25, 2025

  Based on observation, interview, and facility provided documentation, it was determined that the facility failed to ensure all medications were stored in accordance with professional standards by having expired medications in 2 of 2 medication storage rooms inspected. This deficient practice was evidenced by the following: On 08/21/2025 at 10:42 AM the surveyor in the presence of a Register Nurse (RN)# 1, observed a bottle of Sodium Chloride salt tablets (a medication used to replenish low sodium levels in the body) that had and expiration date of 5/2025. The surveyor also observed a bottle of Aspirin 325 mg (a medication commonly used to treat pain) that had an expiration date of 6/2025 in the 3rd floor medication storage room. […]

• No harm, potential for more than minimal, patternF657Mar 7, 2024

  36917 Based on record review, interviews, and review of the facility policy, the facility failed to ensure eight of 27 sampled residents (Resident (R)78, R111, R38, R14, R23, R45, R47, R112) did not have the required participation of all interdisciplinary team members. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 02/01/22, revealed that the comprehensive care plan would be prepared by an interdisciplinary team, that includes, but is not limited to the attending physician or non-physician practitioner designee involved in the resident's care, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, the resident and/or the resident's… […]

• No harm, potential for more than minimal, patternF700Mar 7, 2024

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that side rails were maintained properly for seven of seven residents (Resident (R)7, R14, R38, R45, R96, R101, and R112) reviewed for side rails out of 27 sampled residents. This had the potential to cause entrapment which could potentially cause death. Findings include: Review of the facility's policy titled Proper Use of Side Rails, revised date 02/24, revealed, .3. If a bed or side rail is used, the facility must ensure correct installation, use and maintenance of bed rails, including, but not limited to, the following elements .c. Ensure that the bed's dimensions are appropriate for the resident's size and weight. d. […]

• No harm, potential for more than minimal, patternF578Dec 9, 2021

  Based on observation, interview, policy review and record review, it was determined that the facility failed evaluate residents for Advanced Directives and POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was observed for 12 of 25 residents reviewed for Advanced Directives and POLST, Residents #8, #54, #68, #77, #24, #32, #50, #71, #36, #40, #82 and #103 evidenced by the following: 1. The Admission Record for Resident #8 indicated that the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Minimum Data Set (MDS), an assessment tool used to facilitate the coordination of care, indicated that the resident was able to understand others and able to make themselves understood. […]