Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Bellhaven Center For Rehab And Nursing Care during CMS and state inspections, most recent first.
The facility did not assess residents for entrapment risk, review risks and benefits, or obtain informed consent before installing bed rails for several residents with seizure disorders and cognitive impairment. Instead of using proper side rail pads, staff often substituted blankets and pillows, which were taped or placed over the rails. Staff interviews confirmed this practice was common and that proper pads were difficult to locate. The facility's policy required padded side rails, but there was no evidence of proper assessment, documentation, or maintenance, resulting in Immediate Jeopardy and Substandard Quality of Care.
Several residents with seizure disorders and cognitive impairments were not assessed for bed rail entrapment risk prior to side rail installation, and makeshift padding such as blankets and pillows were used instead of proper side rail pads. The facility's Administrator was aware of and accepted this practice, and there was no documentation of resident or representative education or consent regarding the risks and benefits of side rail use.
The facility did not assess residents for bed rail entrapment risk before installing side rails and used blankets and pillows taped to rails instead of proper padding for several residents. Facility leadership was aware of this practice and considered it acceptable, but the QAPI committee did not review or address the issue.
A resident with cognitive impairment and mobility issues sustained a femoral fracture of unknown origin. The facility's investigation was inadequate, lacking documentation of staff accounts and a resident statement, failing to identify the root cause or rule out abuse, neglect, or mistreatment.
A resident with a language barrier did not have a comprehensive care plan addressing their communication needs. Despite the facility's policy on language services, the care plan lacked interventions for the resident who spoke French Creole. Staff interviews confirmed the oversight, and the facility's Administrator acknowledged the need for a care plan that included language-related interventions.
A facility failed to ensure a physician reviewed a resident's care program, leading to a discrepancy between the Medical Orders for Life-Sustaining Treatment (MOLST) form and physician's orders. The MOLST form indicated intubation and long-term mechanical ventilation, while the physician's order stated not to intubate. The MOLST form had not been reviewed since its completion, contrary to facility policy requiring review every 90 days.
A facility failed to review and update a resident's Medical Orders for Life-Sustaining Treatment (MOLST) form, leading to a discrepancy between the MOLST, the Comprehensive Care Plan, and the physician's order. The resident's MOLST form indicated intubation and long-term mechanical ventilation, while the physician's order and care plan documented a Do Not Intubate directive. The facility's policy required quarterly reviews of the MOLST form, which were not conducted, resulting in this oversight.
Failure to Assess, Educate, and Obtain Consent for Bed Rail Use; Improper Padding Practices
Penalty
Summary
The facility failed to assess residents for the risk of entrapment prior to the installation of bed rails and did not review the risks and benefits of bed rail use with the residents or their representatives, nor did it obtain informed consent. This deficiency was identified for four residents with seizure disorders and varying degrees of cognitive impairment. Documentation in the medical records did not show evidence of risk assessments, education, or consent related to the use of bilateral quarter side rails, despite physician orders and care plans indicating seizure precautions and the use of side rails with padding. Observations revealed that instead of using proper side rail pads, staff frequently substituted blankets and pillows, which were taped or placed over the side rails. Staff interviews confirmed that this practice was common, especially when pads were unavailable, and that locating proper pads was often difficult. The DON, Administrator, and other nursing staff expressed the belief that blankets and pillows provided adequate padding and did not recognize the potential risks of suffocation or entrapment associated with these substitutes. However, a nurse practitioner and the bed manufacturer both indicated that using blankets or pillows could create gaps and increase the risk of entrapment, especially for residents with impaired cognition. The facility's policy required bilateral side rails with padding for residents with seizure diagnoses, but there was no evidence that the facility ensured the side rails and padding were correctly installed or maintained. Observations showed inconsistent and improper padding, and staff interviews revealed a lack of awareness regarding the need for proper assessment, documentation, and the risks associated with makeshift padding. The failure to assess, educate, obtain consent, and use appropriate equipment resulted in a situation of Immediate Jeopardy and Substandard Quality of Care, with a likelihood of serious harm to residents using bed rails.
Failure to Assess and Prevent Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to assess residents for the risk of entrapment from bed rails prior to their installation and did not ensure that the bed rails did not pose a risk of entrapment, asphyxiation, suffocation, or injury. This deficiency was identified for four residents, all of whom had diagnoses such as seizure disorder, muscle wasting and atrophy, cerebral palsy, dementia, and asthma. Observations revealed that these residents had blankets and pillows taped to their side rails in place of proper side rail pads, a practice that was acknowledged and accepted by the facility's Administrator. There was no documented evidence in the medical records that these residents were assessed for entrapment risk before the installation of the side rails, nor that they or their representatives were educated about the risks and benefits or provided consent for the use of the side rails. Physician orders for seizure precautions specified the use of bilateral padded quarter side rails, but in practice, the facility substituted blankets and pillows for proper padding. Multiple observations confirmed the ongoing use of these makeshift pads, and interviews with the Administrator confirmed awareness and acceptance of this practice. The lack of proper assessment, documentation, and use of appropriate equipment directly contributed to the deficiency, with the potential to affect all residents in the facility.
Failure to Address Side Rail Padding Risks Through QAPI
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to address issues related to side rail padding for four of twenty-seven residents reviewed. Specifically, the facility did not assess residents for risk of entrapment from bed rails prior to installation and did not ensure that the bedrails did not pose a risk of entrapment, asphyxiation, suffocation, or injury. Observations revealed that blankets and pillows were attached with tape to the side rails in place of proper side rail pads for these residents, increasing the likelihood of entrapment. Interviews with facility leadership, including the Director of Nursing Services and the Administrator, confirmed awareness of the practice of using blankets and pillows as padding and indicated that this practice was considered acceptable by the facility. The issue had not been discussed or addressed in any QAPI committee meetings, and there was no evidence that the committee had reviewed, analyzed, or acted on available data regarding the identified concern.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who sustained a fracture of unknown origin. The incident involved a resident with diagnoses including Dementia, Type 2 Diabetes, and Major Depressive Disorder, who used a walker and wheelchair for mobility and required assistance for bed mobility and transfer. On 3/19/2024, the resident was found to have a femoral fracture after complaining of left leg pain. The facility's investigation did not identify the root cause of the injury, nor did it include a statement from the resident or detailed staff accounts of any falls or trauma prior to the injury. The Registered Nurse Risk Manager conducted an investigation by interviewing staff who cared for the resident 48 hours before the incident, but the staff responses were not documented. The Director of Nursing Services acknowledged that the staff statements should have included any instances of falls or trauma to rule out abuse, neglect, or mistreatment. The facility's policy required a thorough investigation of injuries of unknown origin, but the documentation was insufficient to rule out abuse, neglect, or mistreatment.
Failure to Address Language Barrier in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed for a resident with a language barrier. Specifically, the care plan for a resident who primarily spoke French Creole did not include interventions to address the language barrier, despite the facility's policy on language services. The resident was admitted with diagnoses including Dementia, Hyperlipidemia, and Hypertension, and was unable to complete a mental status interview. Observations and interviews confirmed that the resident communicated in French Creole, yet the care plan lacked specific measures to address this communication need. Interviews with staff revealed that the regularly assigned Certified Nursing Assistant could communicate with the resident due to shared language skills, but the care plan did not reflect this. A Registered Nurse, who was covering as Unit Manager, acknowledged the oversight and stated that the care plan should have included the language barrier and appropriate interventions. The facility's Administrator also confirmed that a comprehensive care plan should have been in place to address the resident's preferred language, utilizing available resources such as translation services.
Discrepancy in Life-Sustaining Treatment Orders
Penalty
Summary
The facility failed to ensure that a physician reviewed each resident's total program of care, including treatments and medications, as required. Specifically, for one resident, there was a discrepancy between the Medical Orders for Life-Sustaining Treatment (MOLST) form and the physician's orders. The MOLST form, completed on 7/20/2023, indicated that the resident was to be intubated and provided with long-term mechanical ventilation if necessary. However, the physician's order dated 8/10/2024 stated that the resident was not to be intubated. This inconsistency was not addressed, as the MOLST form had not been reviewed since its completion. The facility's policy requires that the MOLST form be reviewed with each 90-day resident review, but this did not occur for the resident in question. Interviews with the Adult-Gerontology Nurse Practitioner and the Medical Director confirmed that the MOLST form should be reviewed to ensure it matches the physician's orders for advance directives. The failure to review and update the MOLST form led to a mismatch between the resident's documented wishes and the physician's orders, highlighting a deficiency in the facility's adherence to its own policies and procedures.
Failure to Review and Update Medical Orders for Life-Sustaining Treatment
Penalty
Summary
The facility failed to ensure that all residents were provided with medically-related social services to maintain the highest practicable physical, mental, and psychosocial well-being. This deficiency was identified for a resident whose Medical Orders for Life-Sustaining Treatment (MOLST) form, dated 7/20/2023, indicated the resident was to be intubated and provided with long-term mechanical ventilation. However, the facility did not review or revise the MOLST form since its completion, leading to a discrepancy between the MOLST form, the resident's Comprehensive Care Plan, and the physician's order, which documented a Do Not Intubate directive. The facility's policy required the MOLST form to be reviewed quarterly during care plan meetings, but this was not adhered to in the case of the resident. Interviews with the Director of Social Work and the Director of Nursing Services revealed that the oversight was due to a failure to ensure consistency between the MOLST form, the physician's orders, and the care plan. The Social Worker responsible for the resident was unavailable for an interview, but another Social Worker confirmed that the MOLST form should be reviewed quarterly with the designated representative, nursing, and social worker during care plan meetings.
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Illustrative
What surveyors actually found near you
We read the 122 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brookhaven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookhaven Health Care Facility, Llc | 2.1 mi | ★★★★★ | 3 | 0 |
| Swan Lake Nursing & Rehabilitation | 3.2 mi | ★★★★★ | 5 | 1 |
| Medford Multicare Center For Living | 4.6 mi | ★★★★★ | 0 | 0 |
| Island Nursing And Rehab Center | 6 mi | ★★★★★ | 0 | 0 |
| Sayville Nursing And Rehabilitation Center | 6.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.