Brooklyn Gardens Nursing & Rehabilitation Center

Inspectors wroteBased on observation, record review, and interviews conducted during the Complaint Survey (Complaint 711914), the facility did not ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. This was evident for 1 of 3 Residents ( Resident #2). Specifically, Resident #2 had physician's order for the treatment of the right medial bunion. A review of the treatment administration record revealed that the treatments were not documented on several occasions.

Inspectors wroteBased on observation, record review, and interviews during the Complaint Survey (iQIES 711881), the facility failed to notify the designated representative of Resident #4's significant weight loss.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (Incident #711926), the facility failed to ensure that residents are free from resident-to-resident abuse. This was evident in two (2) of seven (7) residents (Resident #5 and Resident #7) sampled. Specifically, Resident #5, a known wanderer, wandered into Resident #7's room from a shared bathroom on 01/14/2025 at 8:10 AM. As a result, Resident #5 and Resident #7 were engaged in a resident-to-resident altercation, and Resident #5 sustained an abrasion and swelling to their upper lip.

Inspectors wroteBased on record review, and interviews conducted during an Abbreviated Survey (Incident # 2616975), the facility did not ensure that the results of all investigations pertaining to alleged violations involving abuse, neglect, exploitation or mistreatment, were reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident for three (3) of seven (7) residents (Resident #1, #2, #3) sampled for abuse. Specifically, on 09/14/2025 at 12:40 AM, Resident #3 hit Resident #1 and Resident #2 with a footrest from a wheelchair. Resident #1 sustained injury above their right eyebrow, and Resident #2 sustained a large swelling to their right arm. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from [DATE] to [DATE], the facility failed to ensure that parenteral fluids were administered consistent with professional standards of practice. This was evident in 2 of 3 residents reviewed for hydration. Specifically, 1.) On [DATE], Resident #37, who had physician orders for administration of intravenous solution was observed receiving expired intravenous fluids. 2.) On [DATE], Resident #482's peripheral intravenous catheter insertion site dressing was observed undated. Additionally, the physician's order for Resident #482's intravenous hydration did not include the infusion rate, and assessment and maintenance of intravenous site.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 05/21/2025 to 05/29/2025, the facility did not ensure that food was handled in accordance with professional standards for food service safety and staff did not ensure that infection control practices were maintained in the kitchen. Specifically, Dietary Staff #1 and #2 were observed with visible facial hair while handling and preparing food.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 05/21/2025 to 05/29/2025, the facility failed to ensure infection control protocol were maintained during medication administration. This was evident in 1 (Licensed Practical Nurse #1) of 5 nurses observed. Specifically, Licensed Practical Nurse #1 failed to perform hand hygiene and did not don appropriate personal protective equipment while administering medications to a resident who had a gastrostomy tube.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 05/21/2025 to 05/29/2025, the facility failed to ensure that notice of availability of the survey results were posted in areas of the facility that are prominent and accessible to the public. Specifically, there were no posted notices throughout the facility of the availability of survey results.

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (NY00359265), the facility did not ensure each resident received adequate supervision to prevent an elopement. This was evident in 1 out 16 residents (Resident #1) sampled for elopement. Specifically, the facility Surveillance Camera Recording dated 11/02/2024 showed Resident #1 walked past Security Guard #1 at 11:00 AM, who was sitting at the front desk in the lobby and exited the automatic front doors and eloped from the facility. Resident #1 then walked past a second (Security Guard #2) who was sitting in a booth at the front gate that leads to the street. Facility staff became aware between 12:30 PM and 1:00 PM that Resident #1 was missing. [...]

Inspectors wroteBased on observation, record review, and interviews during an Abbreviated Survey (NY00323964), the facility did not ensure an allegation of abuse was reported to the New York State Department of health (NYSDOH) within two hours after the allegation was made. This was evident for 1 out of 3 residents (Resident #1) sampled for abuse. Specifically, Resident #1 reported on 09/14/23 at 2:00pm that Certified Nursing Assistant (CNA) #1 was rough and hit Resident #1 with the bed sheet on 09/14/23 on the night shift. The facility did not report the alleged abuse within two hours after the allegation was made. The facility reported the abuse allegation on 09/15/23 at 4:28pm.

Inspectors wroteBased on observation, record review, and interviews during an Abbreviated Survey (NY00323964), the facility did not have evidence that an alleged violation of abuse was thoroughly investigated. This was evident in 1 out of 3 resident (Resident #1) sampled. Specifically, Resident #1 reported to Licensed Practical Nurse (LPN) #1 on 09/14/23 at 2:00pm, that Certified Nursing Assistant (CNA) #1 hit Resident #1 with a bed sheet because the volume on the Television (TV) was too loud. Review of the facility's Accident and Incident Report dated 09/14/23, revealed that the facility did not address and implement interventions regarding Resident #1's TV volume.

Inspectors wroteBased on observation, interviews and record reviews conducted during an Abbreviated Survey (NY00323964), the facility failed to ensure that a resident's care plan was reviewed and revised to accurately reflect the status of the resident. This was evident in 1 out of 3 resident (Resident #1) sampled. Specifically, Resident #1 reported on 09/14/23 at 2:00pm that Certified Nursing Assistant (CNA) #1 was rough with them and hit Resident #1 with the bed sheet because the volume on Resident #1's Television (TV) was too loud. Resident #1's care plan was not updated with interventions addressing the volume on the TV.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure person-centered care plans (CCP) was developed and implemented to meet resident needs. This was evident for 3 (Resident #190, #86, and #47) of 38 total sampled residents. Specifically, 1) a CCP related to wandering and elopement was not developed for Resident #190, 2) a CCP related to seizure disorder was not developed for Resident #86, and 3) a CCP related to behavior was not developed for Resident #47.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey (T37011), the facility did not ensure safe food storage was practiced. This was evident during the Kitchen Observation facility task. Specifically, (1) expired honey thickened orange juice and enteral feeding bottles were observed in the dry food storage area. (2) the emergency food storage area was observed with expired thickened orange juice and multiple bottles and boxes of expired enteral feeding.

Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification Survey from 5/9/23 to 5/16/23, the facility did not ensure a safe, clean, comfortable, and homelike environment for residents. This was evident for 1 (Unit 7) of 6 units observed. Specifically, Resident #67 and Resident #47 had wheelchairs that were in disrepair.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure biologicals were stored in accordance with professional principles. This was evident for 1 (6th Floor medication room) of 5 medication storage areas reviewed. Specifically, emergency medications were stored in a plastic emergency box missing the tamper proof seal.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey (T37011), the facility did not ensure that infection control practices were maintained. This was evident for 1 of 6 floors (Unit - 4) observed for Infection Control. Specifically, a Licensed Practical Nurse (LPN #3) was observed using a blood pressure cuff (BPC) on multiple residents without sanitizing the BPC between residents.

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did not ensure a resident's physician was notified and consulted when there was a need to alter treatment significantly. Specifically, the physician was not informed and consulted when a resident's standing order for insulin was withheld several times due to low blood glucose levels. This was evident for 1 out of 35 sampled residents (Resident #132). The finding is: The facility policy for Diabetes Management, last reviewed on 01/2020, documented: The nurse should assess, document, and report the resident's blood sugar history over 48 hours, usual patterns (fluctuations, trends) of blood sugars over recent months, and onset and duration of any changes. Resident #132 was admitted to the facility with diagnoses which include Atrial Fibrillation, Hypertension (HTN), and Diabetes Mellitus (DM). [...]

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did not ensure that services provided met professional standards of quality. Specifically, the licensed nurses did not administer a resident's standing dose of insulin as ordered several times, due to low blood glucose levels, without informing or consulting the physician. In addition, the nursing supervisor was not informed. This was evident for 1 out of 35 sampled residents (Resident #132). The finding is: The facility policy for Diabetes Management, last reviewed on 01/2020, documented: The nurse should assess, document, and report the resident's blood sugar history over 48 hours, usual patterns (fluctuations, trends) of blood sugars over recent months, and onset and duration of any changes. [...]

Inspectors wroteBased on observation, interview, and record review during an recertification survey, the facility did not ensure that a resident receive treatment and care in accordance with professional standards of practice. Specifically, Resident #58 had a surgical wound dressing was not changed as prescribed by the Physician Order. This was evident for 1 of 2 residents (Resident #58) reviewed for Skin Conditions. The finding is: The facility's policy Pressure Injury Prevention and Wound Management last reviewed 1/2020 documented skin care keeping skin clean and lubricated as indicated. Treatment changes will be made according to standards of practice and physician order. Resident #58 is a resident admitted with diagnoses which include Type II Diabetes and Major Depressive Disorder. The Quarterly Minimum Date Set (MDS) Version 3.0 dated 07/29/2020 documented the resident has intact cognition. [...]

Inspectors wroteBased on observations and staff interviews conducted during a recertification survey, the facility did not ensure that all drugs and biologicals were labeled and stored/discarded according to accepted professional principles. Specifically, one Selenium topical lotion, one Foley insertion tray, and two Puracol Collagen Wound Dressing were not discarded after expiration. This was evident for 2 of 6 medication/treatment carts on 2 out of 6 units observed for Medication Storage ( 3rd and 6th floor).