Brooklyn-Queens Nursing Home

Inspectors wroteBased on observation, record review, and interviews during survey, the facility failed to ensure pharmaceutical services was provided (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This was evident for one of five residents (Resident #3) reviewed. Specifically, Resident #3's blister pack with Oxycodone 10 milligrams (30 tablets) and reconciliation (counting) sheet were observed missing on [DATE] at 9:00 PM from a lock narcotic box and has not been located. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the State Survey Agency. This was evident in three (Residents #144, #135, and #68) of seven residents reviewed for accidents and abuse. Specifically, the facility failed to timely report the following incidents to the New York State Department of Health: 1.) On 03/12/2026, Resident #144 intentionally punched a window in their room, shattering the glass and sustaining multiple lacerations to the right hand from broken glass shards; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure all alleged violations were thoroughly investigated. This was evident in three (Residents #144, #135, and #68) of seven residents reviewed for accidents and abuse. Specifically, the facility failed to conduct thorough investigations regarding: 1.) Resident #144, who intentionally punched a window, causing it to shatter and resulting in multiple lacerations and a fractured finger; 2.) Resident #135, who was found on the floor with left orbital swelling and pain and subsequently alleged being pushed; and 3.) Resident #68, who was observed with bruise of unknown origin to the left thigh.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure that a resident who required assistance with activities of daily living received necessary grooming and personal hygiene services. This was evident in one (Resident #95) of three residents reviewed for Activities of Daily Living out of 30 total sampled residents. Specifically, Resident #95, who required staff assistance with personal hygiene, was observed on multiple occasions with unkempt and unshaven facial hair.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a resident requiring oxygen therapy received respiratory care in accordance with physician orders and accepted standards of nursing practice. This was evident in one (Resident #145) of two residents reviewed for respiratory care out of 30 total sampled residents. Specifically, Resident #145 was observed receiving oxygen via nasal cannula at a flow rate of three liters per minute despite a physician's order directing oxygen administration at two liters per minute.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to implement and maintain an effective infection prevention and control program designed to prevent the transmission of communicable diseases and infections. This was evident in one (Resident #18) of four residents observed during medication administration. Specifically, staff failed to follow Enhanced Barrier Precautions when administering medications to Resident #18 via a Percutaneous Endoscopic Gastrostomy tube. The resident's room was clearly identified as requiring Enhanced Barrier Precautions, and facility policy required the use of personal protective equipment during feeding tube care and use.

Inspectors wroteBased on observations, record review and staff interviews conducted during the Recertification survey and Complaint survey (NY00348151) from 09/03/2024 to 09/10/2024, the facility did not ensure that residents comprehensive care plans were reviewed and revised to reflect the resident's status. This was evident for 1 (Resident #91) of 2 residents reviewed for Activities of Daily Living, 1 (Resident #105) of 6 residents reviewed for Abuse and 1 (Resident #7) of 5 residents reviewed for Unnecessary Medication out of 31 sampled residents. Specifically, 1). Resident #91's comprehensive care plan was not reviewed and revised to reflect their preference for wearing hospital-style gowns, and refusal to have their hair care needs addressed, 2). Resident #105's comprehensive care plan related to Victimization was not reviewed and revised after the Minimum Data Set Assessment was completed, and 3). [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 09/03/2024 to 09/10/2024, the facility did not ensure that, to the extent practicable, the resident or resident representative participated in the development, review, and revision of the comprehensive care plan. Specifically, Resident #78 and/or their designated representative were not afforded the opportunity to participate in the initial care plan meeting. This was evident in 1 out of 3 residents reviewed for Care Plan.

Inspectors wroteBased on interviews and record review conducted during the Recertification/Complaint survey (NY00348151) from 09/3/2024 to 09/10/2024, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 1 (Resident #105) out of 6 residents reviewed for Abuse. Specifically, the facility did not report that Resident #105 was found with injuries of an unknown source to the New York State Department of Health within 2 hours.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 09/03/2024 to 09/10/2024, the facility did not ensure that the Minimum Data Set 3.0 assessments were accurately coded to reflect the residents and/or their representatives' participation in the assessment and goal setting. This was evident for 3 (Resident #18, #7, and #78) out of 31 total sampled residents. Specifically, the Minimum Data Set assessment for Residents #18, #7, and #78 did not accurately code that the residents participated in the assessment.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 09/02/2024 to 09/10/2024, the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was evident during the kitchen task and pantry inspections. Specifically, there were multiple expired food items in the kitchen dry storage room, emergency food room, and in the pantry on the 5th floor.

Inspectors wroteBased on observations, record review, and interviews conducted during an abbreviated survey (NY00340994), the facility did not ensure a resident's designated representative was notified of changes in condition. This was evident in 1 out of 5 residents (Resident #1) sampled. Specifically, the Nurse's Progress Note dated 04/29/2024 documented that Resident #1 sustained an excoriation to the right elbow because of friction (the action of one surface or object rubbing against another). The Medical Doctor was notified, and Bacitracin Ointment was ordered. Record review revealed that Resident #1's designated representative was not notified.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00324097), the facility failed to report the results of all investigations 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 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in 1 out of 3 residents sampled (Residents #3). Specifically, on 09/16/2023 at approximately 6:00 pm, Resident #3 was observed on the floor mat in their room. The facility completed their investigation on 10/17/2023 and submitted the findings to New York State Department of Health on 10/17/2023. The facility did not complete and submit the investigation report within 5 working days to New York State Department of Health.

Inspectors wroteBased on observations, record review, and interviews during an abbreviated survey (NY00340994), the facility did not develop and implement a comprehensive person-centered care plan with measurable objectives and time frames to meet a resident's status. This was evident in 1 out of 5 residents (Resident #1) sampled. Specifically, on 04/29/2024 at 3:41 pm, Resident #1 was observed with an excoriation to their right elbow due to friction (the action of one surface or object rubbing against another). A care plan was not developed with interventions to prevent friction.

Inspectors wroteBased on observations, record review, and interviews during an abbreviated survey (NY00340994), the facility did not ensure that a resident care plan was reviewed and revised by the interdisciplinary team. This was evident in 1 out of 5 residents (Resident #1) sampled. Specifically, the facility's Accident/Incident Report dated 05/02/2024 documented at 6:05 pm, Resident #9's visitor reported that Resident #2 walked over to Resident #1 with a knife (black handle stainless steel knife) in their hand on 05/02/2024. The staff were alerted by Resident #9's visitor who took the knife from Resident #2. The facility investigated the incident but did not review and revised Resident #1's care plan.

Inspectors wroteBased on observation, interviews, and record review conducted during an Abbreviated Survey (NY00321311), the facility did not ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 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 or 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). This was evident for 1 out of 3 residents (Resident #1) sampled for abuse. [...]

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated Survey (NY00322751), the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practices, the comprehensive person-centered care plan, and the resident's goals and preferences. This was evident for 1 out of 3 residents (Resident #2) sampled. Specifically, Resident #2 (Resident #1's roommate, who has intact cognition) reported that on 08/24/2023, they heard Resident #2 yelling out that Resident #2 was in pain while Certified Nursing Assistants (CNA #3 and CNA #4) were providing care to Resident #2 on 08/23/2023. CNA #3 reported that they did not report the complaint of pain immediately but reported it to the Licensed Practical Nurse (LPN) #2 after completing care for Resident #2.

Inspectors wroteBased on observation, record review, and staff interviews, during the recertification survey, the facility did not ensure that a resident's comprehensive care plan (CCP) was reviewed and revised with changes in the resident's needs and conditions. This was evident for 1 of 26 residents reviewed in the investigation sample (Resident #47). Specifically, Resident #47's CCP was not reviewed and revised after Resident #47 had an altercation with another resident, (Resident #78)

Inspectors wroteBased on observation, interview and record review conducted during a Recertification and abbreviated survey from 05/21/23 to 05/26/23, the facility did not ensure residents received proper treatment to maintain vision abilities. This was evident for 1 (Resident #78) of 2 residents reviewed for Communication/Sensory out of a sample of 26 residents. Specifically, the facility did assist Resident #78 with obtaining an Ophthalmology consultation.

Inspectors wroteBased on observation, interviews, and record review conducted during a Recertification survey from 05/21/2023 to 05/16/2023, the facility did not ensure a resident received appropriate care and or treatment to prevent potential urinary tract infections (UTI) (Resident #135) . This was evident for 1 of 2 residents reviewed for Urinary Catheter/UTI out of a total investigative sample of 29 residents ( resident #135). Specifically, Resident #135's Foley catheter drainage bag was observed on the floor, and there was no documented evidence that Foley Catheter care was provided or urinary output was monitored. The finding is: The facility policy titled Catheter Care, Urinary dated effective 8/2022 documented the purpose of this procedure is to prevent catheter associated urinary tract infections. [...]

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey from 5/21/23 to 5/26/23, the facility did not ensure that the Minimum Data Set (MDS) 3.0 Assessments were electronically transmitted to the Centers of Medicare/Medicaid Services Data System (CMSDS) within 14 days of completion. This was evident for 2 of 2 resident reviewed for Resident Assessment (Resident # 95 and Resident # 96). Specifically, Resident #95 and Resident #96 had MDS assessments submitted more than 14 days after the completion date.