Brookhaven Health Care Center

Inspectors wroteBased on interviews and record review of pertinent facility documentations on 7/23/26 and 7/24/26, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of attempted sexual assault of a resident (Resident #1), in accordance with the required timeframe for abuse reporting. The facility staff was made aware about the abuse allegation on July 19, 2026, at 9:00 AM, and they did not report the incident to NJDOH till after the surveyor inquiry during the survey on 7/23/26 and 7/24/26. This deficient practice was identified for 1 of 5 residents reviewed for abuse and was evidenced by the following: [...]

Inspectors wroteBased 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. In the prep area on bottom shelf there was a metal bin of prepared cookies next to one red and one green wash and sanitize buckets. The DD said the best practice is to have them separated. 3. [...]

Inspectors wroteBased 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. The RN # 1 removed the two items and said there should not be expired medications in the medication room. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to provide appropriate and sufficient supervision to a resident to prevent an avoidable accident specifically by leaving an unattended cup of medication tablets in a resident's room. The deficient practice was identified for 1 of 2 (Resident 60) Residents review for Accidents. The deficient practice was evidenced by the following: A review of Resident # 60's annual Minimum Data Set (an assessment tool) located in the Electronic Medical Record dated 06/08/2025 (EMR) revealed that he/she had a Brief Interview of Mental Status score of 2/15 indicating that Resident # 60 was severely cognitively impaired. A review of Resident # 60's EMR revealed under Diagnoses, that he/she had a diagnoses of but not limited to unspecified dementia. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, specfically by not administering medication for pain within the required timeframes. The deficient practice was identified for 1 of 3 residents (Resident # 8) reviewed for significant medication errors. The deficient practice was evidenced by the following: A review of Resident # 8's Significant Change Minimum Data Set (MDS; an assessment tool) dated 7/20/2025 revealed that he/she had a Brief Interview for Mental Status score of 15/15 indicating no cognitive deficits. [...]

Inspectors wroteBased on observations, interview, and review of facility documentation it was determined that the facility failed to follow Pharmacy Consultant recommendations for a resident wearing a weekly medication patch. This deficient practice was identified in 1 of 5 residents reviewed for medications (Resident #14) and was evidenced by the following:On 08/19/2025 at 10:13 AM, during the initial tour of the facility the surveyor observed Resident #14 in the day room sitting in a wheelchair during activities. The surveyor reviewed Resident #14 medical record. A review of the admission Record revealed Resident #14 was admitted to the facility with medical diagnoses which included but were not limited to hemiparesis (muscle weakness or partial paralysis on one side of the body) of the right side, hypertension (high blood pressure), and diabetes (high blood sugar). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all medications were administered without error of 5% or more. This deficient practice was observed during a medication administration observation on 8/21/2025. The surveyors observed 5 nurses administer medication to 9 residents a with a total of 33 opportunities, and 7 errors were observed which calculated a medication administration error rate of 21.21% during medication administration observation. This deficient practice was identified for 1of 9 residents (Resident #111) that were administered medications by 1 of 5 nurses on the second-floor nursing unit. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure that one of eight residents (Resident (R) 38) reviewed for side rails from a sample of 27 residents, had a comprehensive, resident-centered care plan.

Inspectors wroteBased on observations, record review, interview and facility policy review, the facility failed to follow physician orders for one of 11 residents (Resident (R)74) reviewed for physician orders. Specifically, the facility failed to apply R74's antiembolism hose to her left leg per the physician orders.

Inspectors wroteBased on observations, record review, interview, and facility policy review, the facility failed to follow physician orders for one of 11 residents (Resident (R)74) reviewed for following physician orders. Specifically, the facility failed to apply R74's left upper extremity splints or provide restorative nursing range of motion (Passive Range of Motion (PROM) on Left Upper Extremity (LUE) and Left Lower Extremity (LLE) and Active Range of Motion (AROM) to Right Upper Extremity (RUE) and Right Lower Extremity (RLE) per the physician orders.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure staff followed physician orders related to oxygen administration for one (Resident (R) 19 of one sampled residents. In addition, the facility failed to assess for one of one sampled residents reviewed for nebulizer treatments (R221) the resident's vital signs or lung sounds before or after administering the nebulizer medication.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure nursing staff properly stored nebulizer masks when not in use for one (Resident (R) 19 of one sampled residents.

Inspectors wroteBased on observation, interview, policy review and record review, it was determined that the facility failed evaluate residents for Advanced Directives and POLST (Physician Orders for Life Sustaining Treatment) related to end of life preferences. 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 which included but were not limited to Peripheral Arterial Disease status post left below the knee amputee; Diabetes Mellitus; Hypertension and Schizophrenia. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to document the administration of medications for 1 of 22 Residents, Resident # 72. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide nail care to residents who were dependent on facility staff for hygiene. This deficient practice was observed for 2 of 22 residents reviewed, Resident # 71 and Resident #77. The deficient practice was evidenced by the following: On 12/1/21 at 10:15 AM, the surveyor observed Resident #71 in bed positioned on their back. The resident did not respond to the surveyor when spoken to. The resident's fingernails on the right hand were long, jagged, soiled and extended beyond the fingertips. The fingernails on the left hand were jagged and soiled. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to properly store and accurately label both prescription and non-prescription medications. This deficient practice was observed for 2 of 2 facility units examined, as evidenced by the following: On 12/1/21 at 9:00 AM, the surveyor observed the 2nd floor registered nurse (RN) prepare medications to be administered to a facility resident. After the medications were prepared, the RN entered the resident's room, leaving the resident's stock medication on top of the medication cart, unattended and not secured. On 12/1/21 at 9:41 AM, the surveyor observed the RN prepare medications to be administered to another facility resident. [...]