Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to conduct and complete quarterly interdisciplinary care conferences for multiple residents with complex medical conditions, including cardiovascular disease, COPD, dementia, and psychotic disorders. Although required MDS assessments and care plans addressing issues such as skin integrity, nutritional risk, and psychotropic medication monitoring were in place, the electronic records showed only sporadic care conferences, many of which were marked in error status or left incomplete with missing signatures and sections. Residents and families reported not participating in quarterly care conferences, and a corporate RN confirmed that the conferences were not held as required and that the facility’s policy calling for resident/family involvement and IDT participation in care planning was not followed.
The facility failed to provide and document evening activities for several cognitively impaired residents whose care plans identified specific activity interests and needs for assistance and verbal prompts. Activity records over a month showed no participation documented after 4:30 p.m., even though the activity calendar listed afternoon and evening programs such as nail care, snacks/hydration, sensory boxes, and movie and snack sessions in the memory care unit. Observations revealed that scheduled activities were not occurring at the designated times, and staff acknowledged that activities were not completed as planned and that documentation after 4:30 p.m. was not monitored, despite policy assigning responsibility for maintaining individual participation records to the activity coordinator.
A resident with multiple comorbidities, cognitive impairment, and dependence for toileting had care plan needs related to constipation and hydration, along with PRN orders for laxatives and a bowel protocol requiring shift-by-shift bowel documentation and action after several days without a bowel movement. Over a multi-day period, the MAR showed no constipation treatments given, CNA documentation and progress notes contained no bowel movement entries, and the NP visit note did not address bowel movement status. An RN and the Administrator confirmed that staff did not document bowel movements daily, did not follow the bowel protocol after several days without a bowel movement, did not administer PRN laxatives, and did not notify the physician or NP of the absence of bowel movements, contrary to facility policy.
A diabetic resident with impaired cognition and vascular dementia, who required assistance with mobility and toileting, did not receive routine foot and nail care despite a care plan directing staff to monitor skin and provide ordered treatments. Physician orders for the month lacked any nail care directives, and there was no documentation that nail care had been performed. Although podiatry services were eventually authorized by the resident’s durable power of attorney, observations later showed the resident complaining of foot pain, with overgrown, curling toenails causing reddened indentations on adjacent toes and white tissue noted between and along the toes.
A resident with neuromuscular bladder dysfunction and an indwelling urinary catheter, who depended on staff for toileting and mobility, was observed receiving catheter care from a CNA. After emptying the urinary drainage bag into a urinal, the CNA reinserted the drainage tubing tip into the storage sleeve without cleaning it with an alcohol pad, contrary to facility policy and the catheter care skills checklist. In interviews, the CNA acknowledged not using an alcohol pad, and an RN confirmed that the tubing end should be wiped with alcohol before reinsertion.
Surveyors found that medications, including topical treatments and a narcotic pain medication with potassium supplement, were left unsecured at the bedside of two residents without staff present. One resident with impaired cognition had a large tub of ointment and roll-on analgesic with pharmacy labels left in the room, while another resident had a medication cup with two pills on the bedside table to self-administer with lunch. The narcotic tablet had not been documented on the controlled substance count sheet, and these practices conflicted with facility policy requiring medications to be locked or attended only by authorized staff.
A resident with multiple wounds and a urinary catheter, care-planned for infection risk and placed on enhanced barrier precautions, received catheter and hygiene care from a CNA who did not don a gown as required, placed a basin directly on a bedside table without a barrier, discarded used washcloths onto a towel on the floor, failed to disinfect the catheter drainage tubing tip before reinserting it into the storage sleeve, and allowed stained bed linens to contact the CNA’s uniform while bagging them. A CDC enhanced barrier precautions sign was posted at the room, washable gowns were available on the back of the door, and facility policy required gown use for high-contact care and device care, but the CNA believed the precautions did not apply to this resident, while an RN confirmed the resident was on enhanced barrier precautions for wounds and catheter use.
The facility failed to maintain a clean kitchen, affecting 91 residents. Observations revealed a tacky substance on hoses and a dark substance on juice box nozzles. Interviews with the Dietary Director and Corporate Dietician confirmed these findings. A review of records showed an undated document for monthly deep cleaning, indicating a lack of documented cleaning procedures.
A resident with severe cognitive impairment and a feeding tube had persistent issues with the tube being black and foul-smelling. Despite repeated notes left for the physician, the facility failed to address these concerns in a timely manner. Observations and staff interviews confirmed the lack of action by medical personnel.
A resident with specific medical conditions had a physician order for Potassium Chloride ER Oral Capsule Extended Release 20 mEq, which required crushing due to swallowing difficulties. However, the facility only had a non-crushable tablet form in stock, leading to improper medication administration throughout November. Despite a signed approval for a crushable form, the order was not initiated, violating the facility's medication administration policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices, as required by their policy. Observations revealed the absence of gowns, gloves, and signage for EBP, and interviews confirmed that these residents were not care planned for EBP. The facility's EBP list did not include these residents, despite their conditions necessitating such precautions.
A resident experienced a fall and a subsequent decline in condition, but the facility failed to notify the resident's emergency contact as required by policy. The LPN mistakenly believed a visiting family member was the emergency contact and did not verify this information, leading to a delay in notifying the actual emergency contact until the resident's condition had significantly worsened.
Failure to Conduct and Complete Quarterly Interdisciplinary Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were prepared, reviewed, and revised by an interdisciplinary team and that care conferences were scheduled and conducted quarterly, as required by facility policy. For one resident with cerebral atherosclerosis, stage IV kidney disease, and hypertension, records showed multiple timely MDS assessments and a care plan addressing risk for skin breakdown, but only one documented interdisciplinary care conference over an extended period. No additional care conferences were recorded in the electronic health record despite ongoing quarterly and annual assessments. Another resident with atrial fibrillation, COPD, chronic pain, and nutritional risk had an admission assessment and several quarterly MDS assessments completed, along with a care plan addressing nutritional risk and monitoring needs. However, the electronic record showed only one documented care conference, and both the resident and family confirmed they had not participated in quarterly care conferences. A third resident with Alzheimer’s disease, dementia, and psychotic disturbance had multiple quarterly and annual MDS assessments and a care plan for psychotropic medication monitoring, but only four care conferences were documented over a broad time frame, with all marked in error status. One of these assessments was incomplete, with only restorative nursing and nursing sections signed, and the resident’s family confirmed that quarterly care conferences had not occurred. A fourth resident with acute and chronic heart failure and vascular dementia with behaviors had multiple quarterly and annual MDS assessments completed and required staff assistance with ADLs. The electronic record showed only two care conferences, both noted as in error status or in progress, and one was incomplete with only restorative nursing and nursing sections signed. A corporate RN verified that the care conference assessments in the system were in error status, meaning the conferences were not complete and/or lacked required information and signatures, and confirmed that quarterly care conferences for all four residents had not been conducted as required. Review of the facility’s Resident Assessment policy showed that residents were to have the opportunity to discuss their goals of care and that care plans were to be developed by an interdisciplinary team with resident and/or family participation, but this policy was not implemented as written.
Failure to Provide and Document Evening Activities for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document resident activities during evening hours, particularly after 4:30 p.m., for residents with impaired cognition. Three residents with dementia or cognitive impairment had care plans and activity assessments identifying interests such as reading, watching television, being outdoors, socializing, and participating in group programs. Their plans of care included interventions like providing activity calendars, assisting and escorting to activities, offering materials for individual activities, and encouraging participation in groups. However, review of their electronic health records over a one‑month period showed no documented activity participation after 4:30 p.m. Surveyors also found that scheduled activities in the memory care unit were not consistently carried out as planned. The March activity calendar listed nail care and snacks/hydration in the afternoon, and repeated evening activities such as sensory boxes and movie and snack sessions. Observations showed that a scheduled nail care activity was not in progress at the designated time, and the snack and hydration activity was not completed as scheduled. Activity staff reported that only two activity staff worked and they left by 4:30 p.m. daily, and that floor staff on the memory care unit were assigned to complete and document evening activities. The Activity Director confirmed that activity participation documentation was silent after 4:30 p.m., that the scheduled activities were not followed on a specific date, and that she did not monitor charting to ensure staff documented resident participation, despite facility policy stating that the activity coordinator maintains individual participation records.
Failure to Monitor and Implement Bowel Protocol for Constipation
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document a resident’s bowel movements and to implement its bowel movement protocol when the resident did not have a bowel movement. The resident had multiple diagnoses including type 1 diabetes, epilepsy, history of myocardial infarction, Lewy body dementia with progressive cognitive decline, constipation, kidney disease stage three, and sepsis, and was cognitively impaired and nonverbal. The resident required supervision for eating, moderate assistance for bed mobility, and was dependent for toileting and transfers. The care plan identified increased nutrition and hydration needs and included monitoring for signs and symptoms of dehydration, monitoring labs and weights, and reporting refusals to eat or swallowing difficulties. Physician orders included a consistent carbohydrate, mechanical soft diet, a PRN Dulcolax suppository for constipation, and a nutritional supplement. Additional PRN laxative and stool softener orders (MiraLax, Colace, Senna) had been discontinued. From early to mid-February, the Medication Administration Record showed no administration of constipation treatments, and CNA bowel movement documentation and progress notes were silent for any bowel movements during the specified period. The NP’s visit note documented a soft abdomen with positive bowel sounds and no acute distress, but there was no documentation of bowel movement status. The RN confirmed that the electronic health record contained no bowel movement documentation after a certain date, that staff were expected to chart bowel movements daily, and that the electronic system should have triggered an alert for assessment and PRN laxative use, which did not occur. The RN also verified that the physician was not notified of the lack of bowel movements. The Administrator confirmed that the bowel movement protocol, which requires bowel movements to be documented every shift and directs staff to consider PRN treatment or physician notification after three consecutive days without a bowel movement, was not implemented, and that daily bowel movement charting and PRN laxative administration after three days did not occur. The NP stated she was not notified that the resident was not having bowel movements.
Failure to Provide Routine Foot and Nail Care for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure routine foot care for a diabetic resident with impaired cognition and vascular dementia. The resident was admitted with diagnoses including acute and chronic heart failure, type 2 diabetes, and vascular dementia, and required setup assistance for eating and moderate assistance for toileting, bed mobility, and transfers. The care plan identified diabetes mellitus with insulin dependence and included interventions such as blood glucose monitoring, diet and medications as ordered, and checking the body for skin breaks. However, review of the physician’s orders for the relevant month showed no orders related to nail care, and the facility was unable to locate any documentation that nail care had been provided. The resident’s quarterly MDS showed impaired cognition without behaviors or rejection of care. The resident initially did not authorize podiatry services per a consent form, but a later podiatry services authorization form showed that the durable power of attorney consented to podiatry services. A weekly nursing skin and body review documented a head-to-toe assessment with no new skin areas noted shortly before the deficiency was identified. Subsequent observations revealed the resident attempting to self-propel in a wheelchair, bumping her foot and stating that it hurt. A focused observation of the left foot showed overgrown nails on the third and fourth toes extending past the end of the toes and curling toward adjacent toes, causing reddened indentations where they touched. The great toe had white-colored tissue at the end of the toe, between the great and second toes, and along the side of the second toe, and the resident complained of pain when questioned by staff. These findings demonstrated that routine foot and nail care had not been provided as needed for this diabetic resident.
Failure to Follow Facility Procedure for Cleaning Urinary Drainage Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate urinary catheter care in accordance with its own policy and skills checklist. A resident with neuromuscular dysfunction of the bladder, intact cognition, and dependence on staff for toileting, transfers, and bed mobility was admitted with an indwelling urinary catheter. The resident’s care plan specified catheter care every shift, changing the catheter bag as needed, and changing the catheter per physician orders. The quarterly MDS documented ongoing urinary catheter use. During an observation, a CNA performed catheter care and then proceeded to empty the resident’s urinary drainage bag into a urinal after performing hand hygiene and donning gloves. After draining the bag, the CNA reinserted the tip of the drainage tubing back into the storage sleeve on the urinary drainage bag without using an alcohol pad to clean the end of the tubing. In a subsequent interview, the CNA acknowledged not using an alcohol pad, and an RN confirmed that staff should clean the end of the drainage tubing with an alcohol pad before reinserting it into the storage sleeve. Review of the facility’s catheter care and urinary output measurement skills checklist from 2009 showed that staff were required to close the drainage outlet, wipe it with an alcohol pad, and then reinsert it into the catheter bag without contaminating it. This failure was identified as an incidental finding during a complaint investigation.
Unsecured Medications Left at Bedside and Failure to Follow Medication Storage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and not left at the bedside unsupervised. For one resident with cerebral atherosclerosis, stage IV kidney disease, hypertension, impaired cognition, and a care plan addressing risk for skin breakdown, physician orders included triamcinolone acetonide cream applied twice daily to the lower legs for stasis dermatitis. During observation of this resident’s room, surveyors found a large tub of ointment and two bottles of roll-on Biofreeze with pharmacy labels left in the room. These medications were present without staff supervision, contrary to the facility’s policy that medications must be locked or attended by authorized personnel. For another resident with atrial fibrillation, COPD, chronic pain, and a care plan addressing pain management, physician orders included daily potassium chloride ER 20 mEq and hydrocodone-acetaminophen 7.5-325 mg every six hours for pain. During observation, this resident was alone in the room in a wheelchair with a lunch tray and a medication cup containing two oval white pills on the bedside table. The resident stated the pills were a pain pill and a potassium pill left for her to take with lunch. The hydrocodone-acetaminophen tablet, a narcotic, had not been signed out on the controlled substance count sheet at the time of observation. The facility’s own medication storage policy states that only licensed nurses or those lawfully authorized to administer medications may access them and that medications must be locked or attended by authorized persons, which was not followed in these instances.
Failure to Follow Enhanced Barrier Precautions During Catheter and Wound-Related Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control program, specifically enhanced barrier precautions, for a resident with multiple wounds and a urinary catheter. The resident had osteomyelitis of the sacral vertebra, peripheral vascular disease, neuromuscular bladder dysfunction, and was dependent on staff for toileting, transfers, and bed mobility. The resident’s MDS showed intact cognition, urinary catheter use, and receipt of ointments/medications to areas other than the feet. The care plan identified the resident as at risk for infection related to wounds and included interventions such as enhanced barrier precautions. Physician orders directed daily wound care to the chest, bilateral calves, and right heel. A CDC enhanced barrier precautions sign was posted outside the room, stating that providers and staff must wear gloves and a gown for high-contact resident care activities, including device care such as urinary catheter care and wound care requiring dressings. During observation, a CNA entered the resident’s room to provide urinary catheter care without donning a gown, despite the enhanced barrier precautions signage and the resident’s status. The CNA performed hand hygiene and donned gloves but placed a basin of warm soapy water directly on the bedside table without a barrier, completed catheter care, then threw the used washcloth onto a cloth towel laid on the floor. After emptying the basin and changing gloves, the CNA emptied the urinary drainage bag into a urinal and reinserted the drainage tubing tip into the storage sleeve without cleaning it with alcohol. The CNA then picked up the towel and dirty washcloths from the floor and placed them in a plastic bag, and also placed a stained bath blanket from the bed into the same bag, allowing the linen to come into contact with the CNA’s uniform. The CNA stated they did not believe the enhanced barrier sign applied to this resident and acknowledged not using a gown. An RN confirmed the resident was on enhanced barrier precautions for wounds and a urinary catheter and that staff should be using gowns for catheter care; washable gowns were observed hanging on the back of the resident’s door. Facility policy required staff to wear an impervious gown for high-contact care, including hygiene, linen changes, toileting assistance, and device care such as urinary catheters and wound care.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen area, which had the potential to affect 91 residents who received meals from the facility's kitchen. During observations on November 18 and November 20, 2024, a tacky substance was found on the hoses, and a dark substance was observed on the nozzles that connect to juice boxes. Interviews with the Dietary Director and Corporate Dietician confirmed the presence of these substances. A review of the facility's records, specifically a document titled 'Monthly Kitchen Deep Clean,' revealed that there was an expectation for Dietary and Maintenance staff to collaborate on a pre-scheduled evening to clean equipment. However, the document was not dated, indicating a lack of documentation regarding the execution of these cleaning procedures.
Failure to Address Feeding Tube Concerns
Penalty
Summary
The facility failed to timely address concerns with a resident's feeding tube, affecting one of two residents reviewed for feeding tubes. The resident, who had severe cognitive impairment and was receiving hospice services, had a feeding tube that was repeatedly noted to be black in color and emitting a foul odor. Despite these observations, there was no documentation of the feeding tube concerns being addressed by the facility physician, Nurse Practitioner, or Hospice staff. Nursing notes indicated that the feeding tube was clogged and later unclogged, but the discoloration and odor persisted over several days. Notes were left for the physician in the communication book on multiple occasions, yet no action was taken until the Hospice on-call physician was notified. Observations confirmed the feeding tube's condition, and interviews with staff, including an LPN and the Director of Nursing, corroborated that the concerns were not addressed by the appropriate medical personnel.
Failure to Administer Medications Per Physician Orders
Penalty
Summary
The facility failed to administer medications according to physician orders for a resident diagnosed with malignant neoplasm of the right kidney, anemia in chronic kidney disease, and unspecified atrial fibrillation. The resident, who was cognitively intact and required assistance with various activities, had a physician order for Potassium Chloride ER Oral Capsule Extended Release 20 mEq to be administered once daily. However, the facility had Potassium Chloride ER Oral Tablet Extended Release in stock, which was not suitable for the resident's needs as the medication was not crushable, contrary to the physician's order to crush medications due to a swallow evaluation result. Throughout November, the resident's medications were crushed and administered daily, except on the morning of the observation when the LPN held the medication due to its non-crushable form. Interviews with the LPN and DON confirmed that a fax form signed by the Nurse Practitioner approved the use of a crushable form of the medication, but this order was not initiated. The facility's policy stated that long-acting or enteric-coated dosage forms should not be crushed, and an alternative should be sought, highlighting a failure in following the policy and physician orders.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, affecting their infection control measures. Resident #75, who was admitted with Parkinsonism, dementia, and neuromuscular dysfunction of the bladder, had a suprapubic catheter but lacked documentation for EBP. Observations on two separate occasions revealed that there were no gowns or gloves available, and no signage was present to advise staff that the resident was under EBP. Similarly, Resident #138, admitted with acute kidney failure, end-stage renal disease, and dependence on renal dialysis, had a dialysis catheter but also lacked EBP documentation. Observations showed the absence of gowns, gloves, and signage for EBP. Interviews with the LPN Unit Manager/Infection Preventionist confirmed that residents with indwelling medical devices should be under EBP, which was not the case for Residents #75 and #138. The EBP list provided to the survey team did not include these residents, and the Director of Nursing confirmed that they were not care planned for EBP. The facility's policy on EBP, dated August 2022, indicated that gloves and gowns should be used for residents with indwelling medical devices, but this was not implemented for the two residents in question.
Failure to Notify Emergency Contact of Resident's Fall and Decline
Penalty
Summary
The facility failed to ensure a resident's emergency contact was notified of a fall and a subsequent change in condition. This deficiency affected one resident who was moderately cognitively impaired and had diagnoses including muscle weakness, vascular dementia, heart failure, and pleural effusion. The resident experienced a fall while attempting to transfer from a wheelchair to the bed, and although the resident's physician and son were notified, the son was not listed as the emergency contact. The resident's level of consciousness declined significantly the following day, but the emergency contact was not notified until later in the evening when they visited the facility and expressed concerns about the resident's condition, leading to the resident being sent to the emergency room for evaluation. Interviews with the Director of Nursing, a Registered Nurse, and the Licensed Practical Nurse (LPN) assigned to the resident revealed that the LPN mistakenly believed a visiting family member was the emergency contact and assumed that the emergency contact had been informed about the fall. The LPN did not verify this information and failed to notify the actual emergency contact about the resident's fall and subsequent decline in condition. The facility's policy requires immediate notification of the resident, attending physician, and the resident's representative or interested family member in the event of an accident or significant change in the resident's status, which was not adhered to in this case.
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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 Brookville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Englewood Health And Rehab | 6.2 mi | ★★★★★ | 0 | 0 |
| Aventura At Shiloh Springs | 6.4 mi | ★★★★★ | 20 | 0 |
| New Lebanon Rehabilitation And Healthcare Center | 6.6 mi | ★★★★★ | 16 | 0 |
| Grace Brethren Village | 6.9 mi | ★★★★★ | 1 | 0 |
| Cypress Pointe Health Campus | 7 mi | ★★★★★ | 6 | 0 |
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