Brookhaven Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Brookhaven Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Oct 3, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for three (Residents #1, #3, and #4) of five residents reviewed for abuse.The facility Administrator and DON failed to protect Resident #1, Resident #3, and Resident #4 from abuse by Resident #2.On 09/09/25, Resident #2 pushed the wheelchair of Resident #4. Resident #4 hit Resident #2. Resident #2 hit Resident #4 back.On 09/29/25 Resident #2 cursed at Resident #1 and Resident #3. He also pulled out a knife from his shoe and threatened them with it.On 10/02/25 Resident #2 threated to kill Resident #1 and chased after her on 10/02/25. Resident #1 suffered psychosocial harm. An IJ was identified on 10/02/25. The IJ template was provided to the facility on [DATE] at 4:50 PM. […]

• Immediate jeopardy, isolatedF689Dec 18, 2024

  Based on observation, interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for 1 of 4 residents (Resident #27) reviewed for accidents and supervision. 1) The facility failed to ensure Resident #27 had adequate supervision when he eloped from the facility on 11/12/24 at 4:41 p.m. The resident left the building through a door which did not sound an alarm when he exited. On 11/13/24, the police found Resident #27 when he attempted to enter a school. The police returned Resident #27 to the facility at 8:24 a.m. Resident #27 was gone from the facility over 15 hours and his whereabouts during the time he was missing were unknown. […]

• Immediate jeopardy, isolatedF689Dec 29, 2023

  Based on observations, record review, and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 11/28/23. 2. The facility failed to ensure an exterior door alarm was reset and functioning properly after allowing an outside vendor to utilize the door for a delivery. The facility concluded Resident #1 eloped through the facility's exit door that did not alarm when opened. The non-compliance was identified as past non-compliance. […]

• Actual harm, isolatedF600Aug 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 1 (Resident #1) of 9 residents reviewed for neglect. 1. The facility failed to ensure Resident #1 was not neglected when she fell from her bed and remained on the floor beside her bed for approximately 4 hours on 07/30/25. 2. The facility failed to ensure RN A and CNA B did Routine Resident Checks every 2 hours on Resident #1 during their shift on 07/30/25. The non-compliance was identified as past non-compliance. The facility corrected the non-compliance before surveyor's entrance. These failures could place residents at risk for humiliation, fear, shame, agitation, decreased quality of life and possibly death. […]

• No harm, potential for more than minimal, patternF638Jul 23, 2025

  Based on interviews and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 2 of 19 residents (Residents #7 and Resident #48) reviewed for quarterly assessments. 1. The facility did not ensure Resident #7's Quarterly MDS Assessment, dated 03/12/2025, was completed within 90 days of the previous assessment. 2. The facility did not ensure Resident #48's Quarterly MDS Assessment, dated 03/19/2025, was completed within 90 days of the previous assessment. These failures could place residents at risk of not having their assessments completed timely.Findings included:1. […]