Bellhaven Center For Rehab And Nursing Care
BELLHAVEN CENTER FOR REHAB AND NURSING CARE in BROOKHAVEN, NY — inspection on September 5, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a telephone interview with the bed manufacture on 08/29/2025 at 9:37 AM they stated they do not sell specific pads to cover the side rails, and they do not have any specific recommendations for padding.
They stated the installation manual states that anything placed on the side of the rails should be tested for entrapment prior to use.
They stated that a pillow or blanket could potentially cause a gap and not pass the entrapment test.
During an interview on 09/26/2025 at 8:58AM, with medical director they stated the blankets and pillows were used temporarily until the pads came in, they stated it is not customary practice.
They stated they do believe an assessment was completed but they are not certain.
They stated everyone is now educated.10NYCRR 415.12(h)(1) (2)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/05/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bellhaven Center for Rehab and Nursing Care
110 Beaver Dam Road Brookhaven, NY 11719
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 8/28/2025 at 11:46 AM, with the Administrator, they stated they were aware resident #3 had blankets and pillows taped to their quarter side rails to be used in lieu of pads.
They stated they have always utilized this practice and found it acceptable.
The Administrator stated they did not think it caused a suffocation or entrapment risk. 10NYCRR 415.26
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/05/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bellhaven Center for Rehab and Nursing Care
110 Beaver Dam Road Brookhaven, NY 11719
SUMMARY STATEMENT OF DEFICIENCIES
Based on observations, record review, and interviews during the abbreviated survey complaint # (NY00375947) the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented appropriate plans of action to correct identified issues with the facility's side rail padding concern identified for four (4) of twenty-seven (27) residents (Resident #1, #2, #3 and #4) reviewed.
Specifically, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation and failed to ensure that the bedrails did not pose a risk of entrapment, asphyxiation, suffocation or injury.
Additionally, the facility had blankets and pillows attached with tape to the siderails of four (4) of four (4) residents siderails in place of side rail pads further adding to the likelihood of entrapment.
The Quality Assurance Performance Improvement Committee did not address, review, analyze, and act on available data on the identified issue to make improvements and to ensure improvements are sustained.Cross Reference:F 700 F 609The finding is:During an observation on 08/26/2025 at 11:36 AM, Certified Nursing Assistant #4 could not locate siderail padding for Resident #1's bilateral quarter side rails.
During an observation on 08/27/2025 at 11:42 AM, Resident #3 was observed in bed with one blanket and one pillow in place over both quarter side rails.During an observation of the unit on 08/27/2025 at 11:48 AM Resident #2's side rails were up with one pad and one blanket over both quarter side rails.
During an observation on 08/28/2025 at 8:10AM Resident #2 was in bed with one pad and one blanket over both quarter side rails.During an observation on 08/28/2025 at 8:20 AM Resident #3 observed in bed with one blanket and one pillow covering both quarter side rails.During an observation on 08/29/2025 at 9:00 AM Resident #3 observed in bed, with both quarter side rails up.
One rail had a pad covering, and the other rail was covered with a pillow.
During an interview on 8/27/25 at 10:05AM with Director of Nursing Services, they stated they were aware that blankets and pillows were being used in lieu of siderail pads on the bilateral quarter side rails.
The Director of Nursing Services stated the nurses are responsible to make sure the siderail pads are in place.
Director of Nursing Services stated that blankets and pillows provided padding, and they (the facility) found it acceptable.
During an interview on 8/28/2025 at 11:46 AM, with the Administrator, they stated they were aware the staff were utilizing blankets and pillows taped to the resident's quarter side rails to be used in lieu of pads.
They stated they have always utilized this practice and found it acceptable.
The Administrator stated they did not think it caused a suffocation or entrapment risk, and the topic has not been discussed at any of our Quality Assurance Performance Improvement (QAPI) committee meetings. 10 NYCRR 483.75 (a)(2)(h)(i)
Facility ID: