Bellhaven Center For Rehab And Nursing Care

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

appropriate form of padding. They stated if the pillows or blankets shift, it could create a risk for entrapment.

Nurse Practitioner #1 stated many of the residents have impaired cognition, and they could get their face stuck and suffocate. 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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bellhaven Center for Rehab and Nursing Care

110 Beaver Dam Road Brookhaven, NY 11719

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

entrapment risk. Resident's # 3 had diagnoses including Seizures, Cerebral Palsy, and Asthma. The minimum data set assessment dated [DATE REDACTED] documented Resident#3's brief interview for mental status score of 99 indicating severe cognitive impairment. It did not document the use of side rails. A physicians' orders dated 08/15/2025 documented seizure precautions, utilize bilateral padded 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 the residents one (1) quarter side rail.During an observation on 08/28/2025 at 8:20 AM, Resident #3 observed in bed with one blanket and one pillow covering one (1) quarter side rail.During an

observation on 08/29/2025 at 9:00 AM, Resident #3 was observed in their bed, with bilateral quarter side rails up. One quarter side rail had a pad covering, and the other quarter side rail was covered with a pillow.

There was no documented evidence in the medical record that Resident #3, was assessed for the risk of entrapment prior to the side rail installation or the resident and representative were educated regarding the risks and benefits and consented to the bilateral quarter side rails. 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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bellhaven Center for Rehab and Nursing Care

110 Beaver Dam Road Brookhaven, NY 11719

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865

Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or potential for actual harm

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)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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