Brooklyn Center for Rehabilitation and Residential

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Complaint (2604985), the facility failed to ensure a resident was free from misappropriation of property. This was evident for one (1) of five (5) residents (Resident #207) reviewed for Abuse out of 38 total sampled residents. Specifically, Certified Nursing Assistant #2 removed Resident #207's dresser key from their arm, opened their dresser, removed $250 from Resident #207's wallet and left the room.

Inspectors wroteBased on observations and interviews, the facility did not ensure that drugs and biologicals were stored appropriately. This was evident for the Medication Storage Task on Unit 2 and Unit 1 (out of 7 units). Specifically, 1). Medications were left unattended in the Unit 2 nurses station, and 2). Expired medical supplies, enteral feeds, and protein supplement were located in the medication room on Unit 1.

Inspectors wroteBased on observation, record review and interviews conducted during the abbreviated surveys (#2652750, and #2610252) the facility failed to ensure that each resident received adequate supervision to prevent accidents. This was evident for two (2) of five (5) residents (Resident #1 and Resident #2) sampled. Specifically, 1). On 10/23/2025, Resident #1 who required a two (2) person mechanical lift transfer out of bed was transferred with one (1) staff only and sustained a fracture of the left hand, and 2). On 09/05/2025, Resident #2 who required a two (2) person mechanical lift transfer out of bed was transferred with one (1) staff only and sustained a fracture of the hip. This resulted in actual harm to Resident #1 and Resident #2 that was not Immediate Jeopardy.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (#2652750 and #2610252), the facility failed to ensure that all alleged violations involving abuse, exploitation, or mistreatment, including injuries of unknown source are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. [...]

Inspectors wroteBased on record review and interview during the abbreviated survey (#2265750), the facility did not ensure a comprehensive person-centered care plan for each resident was reviewed and revised based on changing goals, preferences and needs of the resident and in response to current interventions. This was evident for one (1) out of five (5) residents (Resident #1) reviewed. Specifically, the comprehensive care plan for Resident #1 was not reviewed or revised after Resident #1 fell from a mechanical lift during transfer and sustained injury. The finding is: The facility policy titled 'Care Plan Comprehensive' reviewed 8/2/2024 documented assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change. Resident #1 had diagnoses which included Heart failure and Anxiety. [...]

Inspectors wroteBased on observation, record review and interviews conducted during the abbreviated survey (#2610252) the facility did ensure residents were provided with treatment and care in accordance with professional standards of practice. This was evident for one (1) of five (5) residents (Resident #2) sampled. Specifically, Resident #2, who fell and sustained a fracture of the hip during a mechanical lift transfer from bed, was not assessed and evaluated by a registered nurse before being transferred from the floor back to bed.

Inspectors wroteBased on observation, record review and interview conducted during the abbreviated survey (2610252), the facility did not ensure residents with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. This was evident for one (1) of five (5) residents (Resident #2) reviewed. Specifically, Resident #2 was observed not wearing a right knee or elbow brace as per the plan of care.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Complaint survey from 10/26/23 to 11/2/23, the facility did not ensure safe food storage was practiced to prevent food-borne illness. This was evident during the initial tour of the Kitchen. Specifically, milk past their use by date were located in the kitchen refrigerator.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey completed from 10/26/23 through 11/2/23, the facility did not ensure that each resident was offered the opportunity to participate in the review of their Comprehensive Care Plans (CCP). This was evident for 2 out of 3 residents reviewed for Care Planning out of a sample of 40 residents. Specifically, Resident #89 and Resident #269 were not invited to participate in their care plan meeting.

Inspectors wroteBased on observations, interviews, and record review during the recertification and abbreviated survey conducted from 10/26/23 to 11/2/2023, the facility did not ensure that a resident with limited mobility received appropriate services and assistance to prevent further contractures. This was evident for 1 of 3 resident reviewed for Position/Mobility out of a sample of 40 residents. (Resident #66). Specifically, Resident #66, who had bilateral hand contractures, was observed without bilateral hand rolls in place as ordered.

Inspectors wroteBased on observation, record review, and interview during the Recertification and complaint (NY00317301) survey conducted from 10/26/23 to 11/2/23, the facility did not ensure that the physician reviewed the resident's total plan of care including medications and treatments. This was evident for 1 of 1 resident reviewed for Dialysis (Resident #44) and 1 out of 2 residents investigated for Insulin (Resident #236) out of sample of 40 residents. Specifically, 1) there were no orders in place for a resident who received Dialysis and 2). [...]

Inspectors wroteBased on observation and staff interview during the Recertification survey completed 10/26/23 - 11/02/23, the facility did not ensure that medications and biologicals drugs were stored, labeled, and discarded in accordance with currently accepted professional principles. Specifically, 8 insulin pens were not labeled with open or discard dates. This was evident for 1 out of 5 units observed for the Medication Storage and Labeling facility task. (Unit 2)

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey completed 10/26/23 -11/02/23, the facility did not ensure that a resident requiring oral/dental care was promptly referred for dental evaluation and care. This was evident for 1 of 5 residents reviewed for Dental out of a sample of 40 residents. Specifically, Resident #99 was observed to have a severe buildup of debris at the base of lower gums and had not been scheduled to be evaluated by the dentist.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 10/26/23 to 11/2/23, the facility did not ensure that infection control practices were maintained. This was evident for 1 of 7 units (Unit - 5 ) observed for Infection Control. Specifically, a Home Health Aide (HHA) was observed using a blood pressure cuff (BPC) and pulse oximetry on multiple residents without sanitizing the BPC and pulse oximetry between residents and did not perform hand hygiene between residents.

Inspectors wroteBased on record review and interviews conducted during the Recertification & Complaint (NY00321990) survey from 10/26/2023 to 11/2/2023, the facility did not ensure the resident's right to a dignified existence. This was evident for 1 (Resident #59) out of 40 total sampled residents. Specifically, Resident # 59 was not provided their own personal clothes to wear for an entire weekend after their re-admission to the facility.

Inspectors wroteBased on record reviews and interviews during the Recertification and abbreviated survey (NY00310538 from 10/26/23 to 11/2/23, the facility did not ensure that a resident's representative was immediately notified of the presence of a Stage 3 sacrum ulcer. In addition, the resident's representative was not notified when a Stage 3 sacrum pressure ulcer reopened on June 29, 2023. This was evident for 1 of 1 resident reviewed for Notification of Change (Resident #105).

Inspectors wroteBased on interview and record review conducted during a Recertification and Complaint (NY00318699) survey from 10/26/2023 to 11/2/2023, the facility did not ensure an incident involving a confused resident being unsupervised for about 2 hours in the community was reported to the State Survey Agency. This was evident for 1 (Resident # 18) out of 5 residents reviewed for Accidents out of a sample of 40 residents. Specifically, the facility did not report to the New York State Department of Health (NYSDOH) that Resident #18 was picked up by transportation, left the facility without staff escort, and was dropped off by the transportation on the hospital campus without any staff supervision.

Inspectors wroteBased on interview and record review conducted during a Recertification and Complaint (NY00318699) survey from 10/26/2023 to 11/2/2023, the facility did not ensure an incident involving a confused resident being unsupervised for about 2 hours in the community was thoroughly investigated. This was evident for 1 (Resident #18) out of 5 residents reviewed for Accidents. Specifically, the facility did not obtain the statement from the LPN #1 who took Resident #18 down to the transportation and left the resident unattended by facility staff and complete an incident report thoroughly.

Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification and complaints survey (# NY00317301), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was evident for 1 of 2 residents reviewed for Insulin out of 40 sampled 40 residents. Specifically, Resident #236 admitted with a diagnosis of Diabetes Mellitus had no documented evidence of receiving medication management after 5/18/2023. There was no documented evidence fingerstick were monitored after 8/3/2023, or that insulin coverage was administered for finger sticks over 200mg/dL on multiple occasions, while multiple medical progress notes documented the resident was prescribed insulin and was receiving medication for diabetes. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during a Recertification and Complaint (NY00318699) survey from 10/26/2023 to 11/2/2023, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. This was evident for 1 out of 5 residents reviewed for Accidents out of a sample of 40 residents. Specifically, Resident #18 who was moderately cognitively impaired was picked up unaccompanied at the facility by a transportation company for a clinic appointment at a hospital and was dropped off at the hospital campus unsupervised by the facility staff for approximately 2 hours.

Inspectors wroteBased on observations and interviews conducted during the recertification survey, the facility did not ensure that residents were informed on how to contact the local Ombudsman's office and the New York State Nursing Home Complaint Hotline.

Inspectors wroteBased on observations and interview conducted during the Recertification survey, the facility did not ensure that the most recent survey results and plan of correction were posted in a place readily accessible for review by residents, family members, and legal representatives of residents. Specifically, the survey team did not observe survey results posted anywhere in the facility. In addition, members of the Resident Council were interviewed and reported that they did not know where survey results were posted or accessible for residents to review.

Inspectors wroteBased upon observation, record review and staff interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1) staff were observed not to be wearing a face mask that covered mouth and nostrils; 2). Two dietary aides were observed not wearing beard restraints to prevent hair from contacting food; and 3) a dietary aide was observed exiting the refrigerator and returning to the tray line without performing proper hand hygiene. This was observed during the Kitchen facility task of the Recertification survey.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address a resident's concerns. Specifically, a care plan was not developed to address the care needs of a resident with bilateral hand contractures. This was evident for 1 of 5 residents reviewed for Position/Mobility out of a sample of 38 residents. (Resident #39)

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that the comprehensive care plans were reviewed and/or revised after each assessment and as needed. Specifically, 1). nutrition care plan was not revised to reflect change in resident's status and 2). anticoagulant, Diabetes mellitus and Hypertension care plans were not revised timely. This was evident for 1 of 5 residents reviewed for Position/Mobility and 1 of 5 residents reviewed for Unnecessary Medication out of a sample of 38 residents. (Resident # 211 & Resident #43)

Inspectors wroteBased on observations, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that a resident with limited Range of Motion (ROM) were provided services and treatment to increase ROM and to prevent further decrease in ROM, including the provision of equipment. Specifically, a resident observed with bilateral hand contractures was not being provided with interventions to help maintain and prevent a worsening contracture. This was evident in 1 of 5 reviewed for Limited ROM out of a sample of 38 residents. (Resident #39) The finding is: The facility policy and procedure titled Assistive Devices, created 10/2015 and revised 8/2021, documented that the facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents. [...]

Inspectors wroteIntakes: NY00259235, NY00257504, NY00266680, NY00269559, NY00270774, NY00272515, NY00275893, NY00276408, NY00278916, NY00280691, NY00280817 Based on observation, record review and interviews conducted during the Recertification and abbreviated survey (NY 00270774), the facility did not ensure the physician reviewed and followed up on the resident's entire plan of care. Specifically, the Nurse Practitioner (NP) notes did not reflect the resident's current medical status. Specifically, medications and vital signs were not updated on each visit. This was evident for 1 of 5 residents investigated for Pressure Ulcer/Injury out of a sample of 38 residents. (Resident # 166. ) The finding is: The facility policy and procedure, titled Physician Services dated 04/2021 documented that it is the policy of the facility to ensure the medical supervision of residents care during their stay. [...]

Inspectors wroteBased upon observation, record review and interviews, during the Recertification survey, the facility did not ensure that garbage was properly disposed. Specifically, garbage was not covered while being removed from the kitchen to the disposal area and was not maintained in a closed receptacle. This was evident during the Kitchen facility task. The finding is: The facility policy and procedure titled Food-related Garbage and Refuse Disposal created 6/2015 and revised 12/2020 documented that all garbage and refuse containers are provided with tight fitting lids or covers and must be covered when stored or not in continuous use. The policy also documented that garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. In addition, the policy documented that offsite dumpsters provided by garbage pick-up services will be kept closed. [...]

Inspectors wroteBased on observation and staff interview conducted during the Recertification survey, the facility did not ensure that the daily staffing was posted in a prominent place readily accessible to residents and visitors. Specifically, daily staffing was not observed posted in a prominent place in the building.