Brookhaven Rehab & Health Care Center L L C

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care records were complete and accurately reflected care provided in accordance with accepted professional standards and practices. This was evident for three (Resident #7, #8, and #10) of three sampled residents. Specifically, the facility failed to ensure documentation accurately reflected activities of daily living care, including eating and toileting hygiene, and turning and positioning for residents who required assistance or dependence with these activities.

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (NY00352779), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not involve serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency). This was evident for one (1) out of four (4) residents (Resident #1) sampled. Specifically, Resident #1 was observed on the floor in their room bleeding from their nostrils at around 7:03 AM on 08/20/2024. [...]

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (NY00352779), the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident in one (1) out four (4) residents (Resident #1) sampled. Specifically, Resident #1 who was at risk for fall, was observed on the floor next to their bed bleeding from their nostrils at around 7:03 AM on 08/20/2024 during morning round. Resident #1 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE] with diagnosis of nasal bone fracture. Record review of Resident #1's plan of care revealed Resident #1 has had multiple falls into their room, however, the facility had no documented evidence that the effectiveness of the interventions implemented were evaluated. Additionally, there were no documented evidence of the frequency of monitoring.

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification and Complaint survey (NY00330312) from 03/04/2024 to 03/08/2024, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents reported during confidential interviews and the Resident Council meeting that the facility was short staffed at times especially at night and on the weekends, there was a lack of timely staff response to call bells, 2) multiple nursing staff members reported a lack of sufficient staffing; and 3) analysis of the actual staffing schedule showed that on multiple occasions from January 05, 2024 through February 25, 2024, the facility was below the minimum levels documented on the Facility Assessment.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Complaint survey (NY00326246) from 03/04/2024 to 03/08/2024, the facility did not ensure that residents who are unable to carry out activities of daily living receive the necessary services and assistance to maintain grooming, and personal hygiene. Specifically, resident care was not provided to ensure proper hygiene and grooming. This was evident for 4 of 11 residents reviewed for Activities of Daily Living out of a sample of 38 residents (Resident #21, Resident #165, Resident #98, and Resident #67)

Inspectors wrote2. The facility policy titled Infection Control -Standard Policy last reviewed 11/2023 documented hand hygiene is a major component of standard precautions and one of the most effective methods to prevent transmission of pathogens associated with health care. The policy further documented all individuals including residents should comply with infection control practices in the health-care setting. During an observation of Medication Administration on the 6th Floor on 03/04/24 at 08:30 AM, Registered Nurse #1 was observed administering medication to Resident #80. Registered Nurse #1 removed the resident's medications from the cart and poured the liquid medication into a medication cup, removed, and crushed the tablets, and poured them into the medication cups. Registered Nurse #1 was not observed sanitizing their hands before or after preparing the medication. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 03/04/2024 to 03/08/2024, the facility did not ensure that the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences was maintained. This was evident for 1 of 1 resident reviewed for Accommodation of Needs out of 38 sampled residents. Specifically, Resident #186 was not able to enter the bathroom in their room. The closet, which was placed in a corner of the resident's room, prevented the bathroom door from opening fully to permit Resident #186 to enter the bathroom in their wheelchair.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 3/04/2024 to 3/08/2024, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident on 4 of 5 resident floors (Floors 3, 4, 5 and 6) during review of the Environment. Specifically, 1) Air Conditioning/Heating (AC/H) units were noted to have dirty with debris and in disrepair, missing baseboards in multiple resident rooms and a room noted with discolored floor tiles and a persistent urine odor in a Resident's room, 2) a resident room with a persistently dripping faucet, and 3) a room that did not accommodate resident preference to use toilet in their room.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint (NY00326272) survey from 03/04/2024 to 03/08/2024, the facility did not ensure that a resident was free from misappropriation of property. This was evident for 1 (Resident # 172) of 3 residents reviewed for Abuse out of 38 total sampled residents. Specifically, a Certified Nursing Assistant used Resident #172's Electronic Benefit Transfer (EBT) card to purchase items totaling about $1000.00 without Resident #172's consent.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 03/04/2024 to 03/08/2024, the facility did not ensure an effective discharge planning process was developed and implemented. This was evident for 1 (Resident #186) of 1 resident reviewed for Discharge out of 38 total sampled residents. Specifically, there was no documentation of additional follow-up on a discharge referral for Resident #186.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification and Complaint Survey, from 03/04/2024 to 03/08/2024, the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan. This was evident for 1(Resident #225) of 3 residents reviewed for Respiratory Care out of 38 total sampled residents. Specifically, Resident #225's oxygen cannula/tubing was found on the floor on multiple days, and there was no date on the tubing indicating when the tubing was changed.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Complaint (NY00327102) survey from 03/04/2024 to 03/08/2024, the facility did not ensure that a resident with missing dentures was promptly referred for dental evaluation. This was evident for 1 (Resident #9) of 5 residents reviewed for Dental out of 38 sampled residents. Specifically, the facility policy did not identify those circumstances when the loss or damage of dentures is the facility's responsibility.

Inspectors wroteBased on observations, record reviews, and interviews conducted during the Recertification survey, the facility did not ensure that necessary housekeeping services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, disrepaired handrails, broken and loosely fitted window blinds, broken walls, unpainted areas, mis-matched paint, a blocked bathtub, and cluttered floors were observed in residents' living areas. This was evident in multiple rooms on several units. (Units 2, 3 and 6).

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that each resident or resident representative was offered the opportunity to participate in the revision and/or review of the Comprehensive Care Plan (CCP) and the facility did not ensure a resident's CCP was revised. Specifically, residents were not invited to quarterly care plan meetings and the facility did not revise a resident's CCP following a resident to resident interaction. This was evident for 2 of 5 residents reviewed for Care Planning and 1 of 8 residents reviewed for Accidents out of 38 sampled residents (Resident #177, #143, and #65).

Inspectors wroteBased on observations, and interviews conducted during the Recertification survey conducted 01/06/2022 to 01/12/2022, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases, infections, and COVID-19 within the facility. Specifically, 1) oxygen tubing was undated and was observed lying on the floor, and 2) residents wore their face masks in a manner that did not cover their nose and mouth. This was observed on 2 of 5 units. (Unit 2 and Unit 3) The undated facility policy titled BIPAP/CPAP Filler, Tubing and Mask Change documented it is the policy of the facility to change BIPAP bacteria viral filter, tubing and mask as needed. [...]

Inspectors wroteBased on record review and staff interview conducted during the Recertification and Complaint Survey (NY00282786), the facility did not ensure that residents' representatives were immediately notified about residents' conditions. Specifically, the facility did not notify the resident's representative immediately of the resident's COVID-19 status (Resident #143). This was evident for 1 of 3 residents reviewed for Notification of Change out of a sample of 38 residents. (Resident #143)

Inspectors wroteBased on interviews and record review conducted during the Recertification survey, the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Specifically, the facility did not report a resident-to-resident altercation to the New York State Department of Health (NYSDOH). This was evident for 2 of 9 residents reviewed for Abuse out of a sample of 38 residents. (Resident #65 and Resident #162).

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey, the facility did not ensure that a resident and their representative was provided a summary of the baseline care plan. This was evident for 1 of 5 residents reviewed for Care Plan out of a sample of 38 residents. (Resident # 323) The finding is: The facility policy and procedure titled Comprehensive Care Plans/Baseline Care Plans revised in 6/2019 documented this facility shall develop and implement a Comprehensive Care plan, including a baseline care plan for each residents that includes instructions needed to provide effective and person-centered care of the resident that meet the professional standards of quality of care within 48 hours of a resident's admission. [...]

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification and Complaint survey (NY 00286634), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person centered care plan and the resident's choices. Specifically, 1) compression devices were not applied as per physician's order for a resident with Lymphedema, and 2) wound care treatments were not provided as per physician's orders. This was evident in 2 of 4 residents reviewed for Quality of Care out of a sample of 38 residents. (Resident #81 and Resident #623)

Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification survey the facility did not ensure that pharmaceutical services were provided to meet the needs of each resident. Specifically, 1) the facility did not ensure that resident's prescribed medication was made available in a timely manner by the pharmacy as per order, and 2) the facility did not ensure that expired medications were removed and discarded according to the manufacturer's recommendation. This was evident for 1 of 1 resident reviewed for Vision/Hearing out of a sample of 38 residents and for 1 of 5 medication carts observed. (Resident #99, and 5th Floor)

Inspectors wroteBased on observation, record review and staff interviews during the Recertification Survey the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident and that care was provided in accordance with each resident's Comprehensive Care Plan (CCP). This was identified for 1 (Resident #3) of 1 resident reviewed for Insulin/Anticoagulant use; 3 (Resident #206, #235 and #161) of 6 residents reviewed for Positioning/Mobility; and 1 (Resident #117) of 6 residents reviewed for Unnecessary Medications. Specifically, 1) Resident # 3 had a physician's order to monitor the blood glucose level via fingerstick and to notify the physician if the results were below 70 milligrams/deciliter (mg/dl). On six occasions in April 2019 the fingerstick results were identified at less than 70 (mg/dl) and the physician was not notified; [...]

Inspectors wroteBased on record review and interviews during the recertification survey the facility did not ensure that Accident/Incident (A/I) Reports related to falls were thoroughly investigated. This was identified for 1 (Resident #244) of 1 resident reviewed for accidents. Specifically, Resident #244 had a fall on 5/16/19. The A/I Report did not thoroughly investigate the fall incident regarding the functioning of the resident's call bell, whether the call bell was placed within the resident's reach, and if the resident was wearing footwear at the time of the incident. The finding is: The facility's policy and procedure dated 5/2019 titled A/I Report documented . 6. The Accident/Incident Investigation Report will be completed by the unit nurse, and provide all information required on the form . [...]

Inspectors wroteBased on record review and staff interviews during the recertification survey, the facility did not ensure that each resident's assessment must accurately reflect the resident's status. This was identified for 1 (Resident #161) of 3 residents reviewed for nutrition. Specifically, Resident #161 had a Quarterly Minimum Data Set (MDS) Assessment that was completed on 4/2/19. The MDS documented the resident lost and gained weight during the review period. Review of the resident's weights revealed the resident lost weight throughout the review period, no weight gain had occurred. The finding is: Resident #161 has diagnoses including Morbid Obesity, Major Depressive Disorder, and Type 2 Diabetes Mellitus (DM). The resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did not ensure that each resident's medical record was maintained in accordance with accepted professional standards and practices that is complete and accurately documented. This was evident in 1 (Resident #244) of 41 residents reviewed for medical records. Specifically, Resident #244 had a Physician's Order to administer Oxygen (O2) inhalation via nasal cannula (n/c) at 3 liters per minute (lpm) for O2 saturation <92% for Shortness of Breath (SOB). Review of the medical record revealed that there was no documented evidence that the O2 saturation was monitored prior to the administration of O2 to justify its use. The finding is: Resident #244 has diagnoses including Type 2 Diabetes Mellitus (DM), Major Depressive Disorder, and Shortness of Breath. [...]