Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookhaven Health Care Center during CMS and state inspections, most recent first.
Food handling and sanitation practices were deficient when a large block of cheese in the freezer had no label or date, prepared cookies were stored next to wash and sanitize buckets, and multiple frozen items in the walk-in freezer lacked required labeling or dating. The milk box temperature was elevated, with the thermometer reading 50 degrees F and sampled milk boxes ranging from 46 degrees F to 51 degrees F, and the DOD stated the milk was too warm.
Expired Medications Found in Medication Storage Rooms The facility failed to keep medications stored according to professional standards when expired items were found in 2 medication storage rooms. A surveyor observed expired Sodium Chloride salt tablets and Aspirin in one med room, and an expired 0.9% sodium chloride injection bag in another. RN, an LPN, and the DON all acknowledged that expired items should not have been present in the medication rooms.
A resident with severe cognitive impairment and dementia was observed with four medication tablets left unattended in a cup on the bedside table. The RN/UM stated the nurse should not have left the medications there, and the DON confirmed medications should not be left at the bedside unattended. The facility policy stated that missed medications should be flagged on the MAR and administered later.
Late Administration of Pain Medication: A resident prescribed Lyrica for neuropathy and identified with a pain care plan had multiple doses given outside the ordered timeframe. The resident reported pain from a buttock pressure ulcer and said pain management was not adequate. EMR review showed several AM and PM doses were administered late, and the DON confirmed the doses were late despite the facility policy requiring meds to be given within one hour of the scheduled time.
A resident with HTN, diabetes, right-sided hemiparesis, and severe cognitive impairment had an order for a weekly clonidine transdermal patch. The Pharmacy Consultant recommended checking and documenting patch placement every shift, but the MAR/TAR review found no documentation of patch placement across several months. The DON stated the nurse failed to do this, despite the facility policy requiring monthly pharmacist medication regimen review and written recommendations.
Medication administration errors exceeded the 5% threshold when surveyors observed 5 nurses give meds to 9 residents and found 7 errors in 33 opportunities. An RN preparing meds for a resident with DM, HTN, and thrombosis gave several scheduled meds late, including glimepiride, amlodipine, Eliquis, lisinopril, and brimonidine/timolol, and held ordered premeal insulin after the resident had already eaten breakfast.
The facility failed to ensure the required participation of all interdisciplinary team members in care plan meetings for eight residents. Reviews of electronic medical records and IDT meeting notes revealed missing documentation and incomplete participation from necessary staff, including CNAs, nurses, and physicians. Interviews with staff confirmed these deficiencies, indicating a lack of adherence to the facility's policy.
The facility failed to properly maintain side rails for seven residents, leading to loose rails that posed a risk of entrapment. Despite policies and weekly inspections, the maintenance team did not adequately ensure the safety of the side rails.
A resident with multiple diagnoses, including bipolar disorder and polyneuropathy, was observed using side rails for bed mobility and positioning. However, the care plan did not address the resident's balance issues or the use of side rails, as confirmed by the Social Services Director and the Director of Nursing.
A resident with a physician's order for daily antiembolism hose did not have them applied, leading to discomfort and edema. Staff members were either unaware of the order or assumed others would complete the task, and the LPN signed off on the task without verifying its completion. The DON confirmed the order had been in place but not followed.
A resident with hemiplegia and hemiparesis did not receive the required restorative nursing care, including PROM, AROM, and splint application, as per physician orders. The facility's CNAs were either unaware of their responsibilities or assumed others would perform the tasks, leading to the resident's ongoing discomfort and edema.
The facility failed to follow physician orders for a resident's oxygen administration and did not perform required pre and post-treatment assessments for another resident's nebulizer treatments. Staff were unaware of the correct oxygen setting, and an LPN did not check vital signs or lung sounds as required.
A resident with severe cognitive impairment and pneumonia had their nebulizer mask improperly stored in an unsealed bag, contrary to the facility's infection control policy. Staff confirmed that masks should be sealed to prevent infection, but the policy was not followed.
Food Labeling, Dating, and Temperature Control Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. During observation of the kitchen with the Director of Dietary present, a large block of pepper jack cheese in freezer #1 was wrapped in clear plastic with no label and no date, and the Director of Dietary stated that the smaller cut piece had been labeled but not the larger block. In the prep area, a metal bin of prepared cookies was stored next to red and green wash and sanitize buckets, and the Director of Dietary stated that the best practice is to keep them separated. In the milk box, the inside thermometer showed 50 degrees F, and approximately 45 small boxes of whole milk and 12 small boxes of skim milk were present. The Director of Dietary checked three random milk boxes and found temperatures ranging from 46 degrees F to 51 degrees F, stating that the milk temperature was too high. In the walk-in freezer, a bag of diced green peppers had no label or date, an opened bag of frozen eggplant had no label or opened date, and a box of pierogies had ice on top and was dated 2/17/25. The surveyor also reviewed the facility's labeling and dating protocol and milk holding box policy, which required fresh and frozen foods to be dated and milk box temperatures to be monitored twice daily.
Expired Medications Found in Medication Storage Rooms
Penalty
Summary
The facility failed to ensure medications were stored in accordance with professional standards by having expired medications in 2 of 2 medication storage rooms inspected. In the 3rd floor medication storage room, a surveyor observed a bottle of Sodium Chloride salt tablets with an expiration date of 5/2025 and a bottle of Aspirin 325 mg with an expiration date of 6/2025 while accompanied by RN #1, who removed the items and stated there should not be expired medications in the medication room. In a separate observation the next day, a surveyor and UMLPN #1 found a 50 mL 0.9% sodium chloride injection bag with an expiration date of 06/2025 in the medication storage room, and the UMLPN stated she usually cleans out the med room on Fridays and there should not be anything expired in the room. The DON later stated that there should not be expired items in the medication storage room. The facility policy titled Medication Labeling and Storage stated that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Unattended Medication Left at Bedside
Penalty
Summary
The facility failed to provide appropriate and sufficient supervision to prevent an avoidable accident when a cup containing four medication tablets was left unattended on a resident’s bedside table. The resident was observed in the room with the medication cup present during the initial tour, and the RN/UM stated that the nurse should not have left the medications at the resident’s bedside. The affected resident had a BIMS score of 2/15 on the annual MDS dated 06/08/2025, indicating severe cognitive impairment, and had a diagnosis of unspecified dementia. During interview, the DON stated that medications should not be left at the bedside unattended because somebody can take it or it might be missed. The facility policy titled Administering Medications stated that if residents are not in their rooms or otherwise unavailable to receive medication, the MAR may be flagged and the nurse should return later to administer the medication.
Late Administration of Pain Medication
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident who was prescribed Lyrica 75 mg twice daily for neuropathy and had a care plan focus for pain related to a medical condition/diagnosis. The resident’s MDS dated 7/20/2025 showed a BIMS score of 15/15, indicating no cognitive deficits. During the initial tour on 08/19/2025, the resident was observed in bed and stated that he/she had a pressure ulcer on the buttocks that caused pain and that pain management was not adequate. Review of the EMR medication audit showed multiple doses of Lyrica scheduled for 09:00 AM and 09:00 PM that were administered late, including morning doses given at 10:53 AM, 10:38 AM, 10:37 AM, 12:30 PM, and 11:52 AM, and evening doses given at 10:23 PM, 10:50 PM, and 10:44 PM. The DON stated that medications can be given one hour before and one hour after the scheduled time and confirmed the doses were late. The DON also stated the nurse had to call the doctor and check for adverse effects. The facility policy stated medications are to be administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.
Failure to Document Weekly Clonidine Patch Placement
Penalty
Summary
The facility failed to follow Pharmacy Consultant recommendations for a resident using a weekly clonidine transdermal patch for hypertension. Resident #14 was admitted with diagnoses including right-sided hemiparesis, hypertension, and diabetes, and the quarterly MDS dated 8/1/25 showed a BIMS score of 3, indicating severe cognitive impairment. The physician order summary showed clonidine transdermal patch weekly on Saturdays, with instructions to rotate sites and remove per schedule, and the care plan included interventions to administer medications as ordered and observe for side effects such as orthostatic hypotension and increased heart rate. The Pharmacy Consultant’s April 2025 monthly medication review recommended checking clonidine patch placement every shift and documenting it accordingly. However, review of the April, May, June, July, and August 2025 MARs and TARs did not locate documentation of clonidine patch placement. The DON stated that checking patch placement was important to ensure it remained on the resident to keep blood pressure stable, and stated that the nurse failed to do that. The facility policy on Pharmacy Services-Role of the Consulting Pharmacist stated that the consultant pharmacist will provide a documented monthly review of each resident’s medication regimen and written reports and recommendations related to medication and pharmaceutical services review.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure medications were administered without an error rate of 5% or greater. During a medication administration observation, surveyors observed 5 nurses administer medications to 9 residents across 33 opportunities and identified 7 errors, resulting in a 21.21% medication administration error rate. The deficient practice was identified for 1 of 9 residents on the second-floor nursing unit when an RN was observed preparing medications for a resident with diagnoses including Type 2 diabetes mellitus, hypertension, and thrombosis of the lower extremity. During the observation, the RN checked the resident’s blood sugar at 219 mg/dL and drew up 4 units of insulin aspart, then began to draw up an additional 10 units of insulin aspart ordered before meals. After the surveyor asked to see the order, the RN decided to hold the insulin until speaking with the doctor because the resident had already eaten breakfast. The RN then administered the resident’s remaining medications late: glimepiride, amlodipine, Eliquis, lisinopril, and brimonidine/timolol, all of which were scheduled for earlier times. The RN stated she was late with all of the resident’s medications, and the DON stated medications should be given within an hour before to an hour after the scheduled time, while insulins ordered before meals should be given on time and before the resident eats.
Failure to Ensure Required Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure the required participation of all interdisciplinary team (IDT) members in the care plan meetings for eight of 27 sampled residents. The facility's policy mandates that the comprehensive care plan be prepared by an IDT, including the attending physician, a registered nurse, a nurse aide, a member of the food and nutrition services staff, the resident and/or the resident's representative, and other appropriate staff. However, the review of the electronic medical records (EMR) and IDT meeting notes revealed that the participation of these members was not documented or was incomplete for several residents. For instance, Resident 78 and Resident 111, both cognitively intact, reported not being notified or attending any care plan meetings. Similarly, Resident 38's IDT meeting notes lacked evidence of participation from a CNA, nurse, or physician/designee in multiple meetings over a year. Resident 14's IDT meetings also had no documentation of which staff, resident, or representative attended the meetings on several occasions. Further review showed that Resident 23's IDT meeting notes failed to include the nursing department and other required staff in multiple meetings. Resident 45's IDT meeting notes were often blank or missing documentation of attendance from the nursing department and other required members. Resident 47's IDT meeting notes consistently lacked notation from dietary, social services, or activities staff. Lastly, Resident 112's IDT meeting notes failed to include the nursing department's participation. Interviews with staff, including the Director of Nursing (DON), confirmed these deficiencies, indicating that the facility did not adhere to its policy of having all required IDT members participate in care plan meetings. The interviews with various staff members, including CNAs, RNs, and the Social Services Director, revealed inconsistencies in the understanding and execution of the care plan meeting process. Some staff indicated that CNAs no longer attended care plan meetings, while others mentioned that key players such as the unit manager, dietician, therapy, social services, family, and resident should be present. The DON stated that her expectation was for anyone attending the meeting to sign an attendance sheet, which was not consistently done. This lack of adherence to the facility's policy and the absence of required IDT members in care plan meetings led to the identified deficiencies in the care planning process for the residents involved.
Failure to Maintain Proper Side Rail Safety
Penalty
Summary
The facility failed to ensure that side rails were maintained properly for seven residents, which had the potential to cause entrapment and potentially lead to death. The facility's policy on the proper use of side rails required correct installation, use, and maintenance, including ensuring that bed dimensions were appropriate for the resident's size and weight, and following the manufacturer's recommendations for installation and maintenance. However, observations and interviews revealed that side rails for seven residents were loose and not properly maintained, despite the facility's policy and procedures. One resident, who was readmitted with multiple diagnoses including bipolar disorder and polyneuropathy, had an order for half side rails for bed mobility, but the side rails were found to be loose. Another resident with severe cognitive impairment had side rails for positioning, but both side rails were loose. Similarly, a resident with end-stage renal disease had side rails for positioning, but the left side rail was loose. Another resident with severe cognitive impairment had reported a loose side rail multiple times, but no action was taken to tighten it. Further observations and interviews with the Maintenance Director revealed that the maintenance team was responsible for inspecting and maintaining bed rails. However, the inspection process was inadequate, as evidenced by the loose side rails found in multiple residents' beds. The Maintenance Director confirmed that some beds had a pin lock with no bolt to tighten the rails, while others had a round knob for tightening. Despite weekly inspections, the side rails for all seven residents were found to be loose, indicating a failure in the facility's maintenance and inspection procedures.
Lack of Comprehensive Care Plan for Side Rail Use
Penalty
Summary
The facility failed to ensure that a resident had a comprehensive, resident-centered care plan for the use of side rails on the bed. The resident, who was readmitted to the facility with diagnoses including bipolar disorder, adjustment disorder, disruptive mood disorder, and polyneuropathy, was observed in bed with bilateral side rails in the up position. The resident's order summary indicated the use of half side rails for repositioning and bed mobility. However, the care plan did not address the resident's difficulty in balance and poor bed mobility or the use of side rails for positioning. Interviews with the Social Services Director and the Director of Nursing confirmed the absence of a comprehensive care plan for the resident's use of side rails.
Failure to Follow Physician Orders for Antiembolism Hose
Penalty
Summary
The facility failed to follow physician orders for a resident (R74) who was supposed to have antiembolism hose applied to her left leg daily. Despite the physician's order dated 02/02/23, observations and interviews revealed that the hose were not applied. R74, who was cognitively intact with a BIMS score of 15 out of 15, was unaware of the order and reported discomfort and edema in her left lower extremity. Multiple staff members, including CNAs and an LPN, confirmed that they had not applied the hose and were either unaware of the order or assumed someone else would complete the task. The LPN admitted to signing off on the task without verifying its completion. The Director of Nursing (DON) was informed of the situation and confirmed that the order for antiembolism hose had been in place since 02/02/23. There was no documentation indicating that the hose had been offered or refused by the resident. This lack of adherence to physician orders and proper documentation led to the deficiency noted in the report.
Failure to Follow Physician Orders for Restorative Nursing Care
Penalty
Summary
The facility failed to follow physician orders for a resident (R74) who required specific restorative nursing care to maintain and improve range of motion (ROM). The resident, who was admitted with hemiplegia and hemiparesis following a cerebrovascular incident, had physician orders for passive range of motion (PROM) on the left upper and lower extremities, active range of motion (AROM) on the right upper and lower extremities, and the application of left upper extremity splints. Despite these orders, the facility did not consistently provide the required care, as evidenced by the resident's electronic medical record and interviews with staff and the resident herself. The resident reported not receiving any range of motion assistance for a long time, and staff interviews confirmed that the restorative nursing tasks were not being performed as required. The facility's policy indicated that the primary caregiver or designated CNA should be informed of the resident's restorative nursing needs, but this was not effectively communicated or implemented. The Director of Nursing (DON) acknowledged that the facility no longer had a restorative nursing assistant and that the CNAs were expected to perform the restorative nursing program tasks. However, the CNAs were either unaware of these responsibilities or assumed that another staff member would handle them. This lack of communication and follow-through resulted in the resident not receiving the necessary care to maintain and improve her range of motion, leading to ongoing discomfort and edema in her left lower extremity.
Failure to Follow Physician Orders for Oxygen and Nebulizer Treatments
Penalty
Summary
The facility failed to ensure staff followed physician orders related to oxygen administration for a resident diagnosed with pneumonia and severe cognitive impairment. The resident was observed wearing a nasal cannula with the oxygen setting at 2 liters per minute (LPM) on multiple occasions, despite a physician order for continuous oxygen at 3 LPM. The Treatment Administration Record (TAR) indicated that the oxygen was signed off as being administered at 3 LPM, but staff interviews revealed that the oxygen was actually set at 2 LPM, and the staff were unaware of the correct physician order. The Director of Nursing confirmed that staff are expected to follow physician orders exactly, and the facility's policy also required correct flow rate administration as ordered by a physician. Additionally, the facility failed to assess a resident's vital signs or lung sounds before or after administering nebulizer medication. The resident, who had a diagnosis of end-stage renal disease and shortness of breath related to heart failure, had a physician order for nebulizer treatments that included pre and post-treatment assessments of pulse, respirations, and lung sounds. However, an LPN admitted to not performing these assessments during an observation and interview. The Director of Nursing confirmed that it was her expectation for all nurses to follow physician orders and perform the required assessments before and after nebulizer medication administration.
Improper Storage of Nebulizer Masks
Penalty
Summary
The facility failed to ensure proper storage of nebulizer masks for a resident diagnosed with pneumonia. The resident, who had severe cognitive impairment as indicated by a BIMS score of 03 out of 15, had their nebulizer mask placed inside an unsealed bag on the dresser by their bed. This was observed on multiple occasions. The facility's policy required that nebulizer masks be stored in sealed plastic bags labeled with the resident's name and date to prevent infection control issues. However, the nebulizer mask was found in an unsealed bag with the tubing still attached, making it impossible to seal the bag properly. Interviews with the nursing staff, including two LPNs and the Director of Nursing, confirmed that the nebulizer masks should be stored in sealed plastic bags to prevent infection. The observations and interviews revealed that the facility did not adhere to its own infection control policy, leading to a deficiency in proper infection prevention and control practices. The facility's policy on infection control, dated January 2024, was not followed, resulting in a potential risk for infection for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near East Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White House Healthcare And Rehabilitation Center | 0.6 mi | ★★★★★ | 11 | 0 |
| Alaris Health At St Marys | 0.8 mi | ★★★★★ | 2 | 0 |
| Grove Park Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 11 | 1 |
| Complete Care At Orange Park | 1.8 mi | ★★★★★ | 13 | 0 |
| Park Crescent Healthcare & Rehabilitation Center | 1.9 mi | ★★★★★ | 12 | 0 |
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