Brooklyn United Methodist Church Home

Inspectors wroteBased on observations, record review, and interviews conducted during an abbreviated survey (NY00360005), the facility did not ensure a resident's designated representative was notified of changes in condition. This was evident in one out of three residents (Resident #2) sampled. Specifically, a Health Status Note dated 11/05/2024 documented Resident #2 complained of left eye pain. An assessment was done and revealed mild swelling to the left eye. The Medical Doctor was informed and an ordered for Diclofenac eye drops. There is no documented evidence that Resident #2's designated representative was notified of the changes in condition.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00372860), the facility did not ensure that a resident was free from abuse. This was evident for one (1) out of nine (9) residents (Resident #1) sampled. Specifically, the facility's dining room surveillance video recording dated 02/22/2025 showed at 9:05 AM Certified Nursing Assistant #1 hit Resident #1 on their left upper shoulder (once) with the back of their left hand, then walked out of the dining room, after Resident #1 threw liquid on Certified Nursing Assistant #1 who was standing behind them. Housekeeper #1, who was in the dining room, then walked over to Resident #1 and wheeled the Resident out of the dining room at 9:08 AM. Resident #1 was assessed by Registered Nurse Supervisor #1 with no visible injury, pain, or discomfort.

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (NY00372860), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involved abuse or resulted 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. This was evident in one out of nine (9) residents (Resident #1) reviewed. [...]

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey from 01/02/2025 to 01/10/2025, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 3 (Residents #47, #51, and #99) of 3 residents reviewed for Beneficiary Notification. Specifically, the facility did not provide appropriate notification at least two calendar days before Medicare covered services ended as required and did not provide the designated form for notification in the nursing home setting.

Inspectors wroteBased on observations and staff interviews during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of ceiling tiles and resident equipment and found to be unsanitary and in disrepair. This was evident for 1 of 3 resident units (Unit 3).

Inspectors wroteBased on observations and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025 the facility did not ensure a safe functional environment for residents, staff, and public. This was evident for the staff bathroom and nursing station on 1 (Unit 3) of 3 Units. The finding is: The facility policy titled Homelike Environment dated 10/02/24 stated that residents are provided with a safe, sanitary and orderly environment. During multiple observations on the 3rd floor unit from 01/02/2025 to 01/10/2025 the following was observed: 1. The Staff bathroom adjacent to the Tub Room had a loose and wobbly toilet seat. 2. in the Nurse's Station: a. the Plexi glass was covered with dust, dirt and streaks. b. two swivel chairs were layered with dirt and dust. c. the call bell console was layered with dust and dirt d. [...]

Inspectors wroteBased on observation, and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #76) of 1 resident reviewed for Pressure Ulcer out of a sample of 27 residents. Specifically, Licensed Practical Nurse #2 failed to practice appropriate infection control and placing the barrier on a visibly soiled overbed table and did practice appropriate hand hygiene and glove changes during wound care.

Inspectors wroteBased on observations and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure that survey result reports for the 3 preceding years were readily available to residents and visitors upon request. Specifically, upon review of the survey binder, only survey results for the year 2023 were included in the survey binder. In addition, notice of the availability of the survey results reports was not posted in areas of the facility that are prominent and accessible to the public.

Inspectors wroteBased on observations and interviews during the Recertification survey from 01/02/2025 to 01/10/25, the facility did not ensure that total number of nursing staff and actual nursing staffing hours are posted in a prominent place readily accessible to the residents and visitors.

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (Case # NY00334732), the facility failed to ensure that a resident, identified as an elopement risk received adequate supervision to prevent elopement from the facility. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 03/01/2024, Resident #1, who had severely impaired cognition and had a wander alert device in place since 02/29/2024 at 10:01 pm, left the building undetected at 11:49 am. Facility staff became aware that Resident #1 was missing from the unit on 03/01/2024 at approximately 12:20 pm. Resident #1 was located by Resident #1's relative on 03/01/2024 and notified the facility at 5:30 pm that Resident #1 was at the hospital and would be returning to the facility. On 03/01/2024 at 10:05 pm, Resident #1 returned to the facility. [...]

Inspectors wroteBased on observations and staff interviews conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This was evident for the total census of 113 residents. Specifically, the daily staffing information was observed posted on the wall near the staff time clock, not in a prominent place readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure the residents had a right to organize and participate in resident groups in the facility. This was evident during Resident Council wit Resident #64, #95, #39, #118, #53, #56, and #16. Specifically, the facility did not take reasonable steps to organize and assist residents with meeting regularly as a Resident Council.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure residents were provided with the contact information for the State Long Term Care Ombudsman (SLTCO). This was evident in the lobby and 1 (3rd Floor) of 3 units. Specifically, the posted telephone number for the SLTCO was incorrect in the lobby and on the 3rd Floor.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and complaint (NY00310185), the facility did not ensure the residents' right to a safe, clean, comfortable environment. This was evident for the outdoor patio and 3 of 3 resident floors (2nd, 3rd, and 4th). Specifically, 1) the outdoor patio was observed with paper cups, gloves, and cigarette butts on the ground and overgrown shrubs, trees, and grass; 2) the 2nd floor was observed with sticky dirty furniture, sticky floors stained black at the baseboards, broken dressers, peeling paint, sagging unhooked privacy curtains, a bed frame in disrepair, missing mirror, urine odor, and a stained faucet with a loose handle in resident rooms and dirty air conditioning (AC) units in the dayroom; [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification and abbreviated survey (NY00302016 and NY00318527) from 9/10/2023 to 9/18/2023, the facility did not ensure all alleged violations involving abuse were reported within 2 hours, or events not involving abuse were reported within 24 hours to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #92) of 3 residents reviewed for abuse and 1 (Resident #79) of 2 residents reviewed for accidents out of 27 total sampled residents. Specifically, 1) Resident #92 reported a Certified Nursing Assistant (CNA) pushed them in the chin and the facility did not report the allegation to the NYSDOH within 2 hours, and 2) the facility did not report Resident #79 was found on the floor in their room with left arm redness and sheering within 24 hours.

Inspectors wroteBased on record reviews, and staff interviews during the recertification and abbreviated (NY00318546 and NY00318527) survey from 9/10/2023 to 9/18/2023, the facility did not ensure all alleged violations of abuse were thoroughly investigated. This was evident for 2 (Resident #171 and #79) of 27 total sampled residents. Specifically, 1) Resident #171 was observed with a bump and redness to their forehead that was not thoroughly investigated, and 2) staff statements were not obtained to rule out abuse when Resident #79 was found on the floor.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed and implemented. This was evident for 5 of 27 sampled residents (Resident #s 60, 109, 110, 66, and 27). Specifically, Resident #60 had no CCP for Glaucoma. Resident #66 and #109 had no CCP developed to address dental issues. Resident #110 had no CCP developed to address the care needs of Latent Syphilis. Resident #27 had no CCP to address pain.

Inspectors wroteBased on observations, interviews and record review conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure resident's Comprehensive Care Plan (CCP) were reviewed, revised, and implemented after each assessment. This was evident for 1 of 2 residents reviewed for Pain Management (Resident #87) and 1 (Resident #79) of 2 residents reviewed for Accidents out of 27 total sampled residents. Specifically, 1) CCPs related to Pain Management/Therapy were not reviewed and revised quarterly to reflect current pain management regimen for Resident #87, and 2) the CCP related to Resident #79's risk for falls was not reviewed and revised to reflect updated interventions after the resident had an incident on 6/19/2023.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and complaint (NY00318527) survey from 9/10/2023 to 9/18/2023, the facility did not ensure residents remained free of accidents and hazards. This was evident for 1 (Resident #79) of 2 residents reviewed for Accidents and the 1 (2nd Floor) of 3 resident units. Specifically, 1) Resident #79 was not adequately assessed for fall risk following each fall, did not have a CCP related to fall risk with adequate interventions that was reviewed upon each fall, and did not receive supervision to prevent further falls; and 2) there were observations of a 2nd floor window in the floor dayroom that can fully open, an eyewash station without an eyewash device in place, a dental office with an x-ray machine and drill that remained unlocked, and a wet shower room floor without a wet floor sign.

Inspectors wroteBased on observation, record review, and staff interviews conducted during the recertification and complaints (NY00307070, NY00318546, survey from 9/10/23 through 9/18/23, the facility did not ensure there was sufficient staff available to meet residents' needs considering the number, acuity and diagnose of the facility's resident population as determined by the Facility Assessment. Specifically, 1) the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal (PBJ) Staffing Data Report, 2) Resident #171 was discovered with an injury of unknown origin on a day when the unit was short of Certified Nursing Assistants (CNA), and 3) Resident #121 reported not receiving care on a day when the facility was short of CNAs on their unit.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident during 7 of 7 Licensed Practical Nurse (LPN) Permittees and 1 of 1 Registered Nurse (RN) Permittees employed by the facility. Specifically, the facility employed 7 LPN Permittees and 1 RN Permittee to work in the capacity as a licensed nurse without the required application approval and documented RN supervision.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 9/10/2023 to 9/18/2023,the facility did not ensure a quality assurance and performance improvement (QAPI) program that use evidence to define and measure indicators of quality and facility goals, include resident choice, and address all systems of care and management practices. This was evidenced Specifically, the facility's QAPI topics were not reflective of previous State Survey Inspection results and the method of gathering measurable data was not accurate or adequate to identify quality improvement.

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification and complaint (NY00310185) from 9/10/2023 to 9/18/2023, the facility did not ensure a safe, functional, and comfortable environment for residents, staff, and the public. This was evident for the outside area of the facility and 1 (2nd floor) of 3 Units. Specifically, the outside surrounding area of the nursing home had overgrown grass and shrubs and garbage on the sidewalks and in the parking lot, and insects hovering around standing water in a cart near the entrance to the facility; and, the 2nd Floor had a nursing station that had chipped and missing veneer and broken filing cabinets.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure a resident's right to formulate an advance directive (AD). This was evident for 1 (Resident #371) of 33 total sampled residents. Specifically, Resident #371's AD status was not determined with their Legal Guardian (LG) upon readmission to the facility.

Inspectors wroteBased on record review and staff interviews conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were completed in a timely manner. This was evident for 2 (Resident #103, #105) of 2 residents reviewed for Resident Assessment. Specifically, 1) Resident #103's Discharge MDS was not completed within 14 calendar days from the Assessment Reference Date (ARD), and 2) Resident #105's Discharge MDS was not completed within 14 calendar days from the Assessment Reference Date (ARD).

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and complaint (NY00318527) from 9/10/2023 to 9/18/2023, the facility did not ensure services met professional standards of practice. This was evidenced for 1 (Resident #79) of 27 total sampled residents. Specifically, Resident #79 was found on the floor in their room and was placed back in bed by the Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) prior to receiving an assessment by a Registered Nurse (RN).

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure a resident received quality care. This was evident for 1 (Resident #24) of 27 total sampled residents. Specifically, Resident #24 was observed on multiple occasions without compression stockings in place as ordered to address left lower extremity (LLE) edema.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 9/10/23 to 9/18/23, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for Resident #371 reviewed for Position/Mobility out of 27 total sampled residents. Specifically, Resident #371 had bilateral upper and lower extremity contractures and was observed without an abduction/contraction cushion (ACC) as per Medical Doctor Order (MDO).

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification and abbreviated survey, the facility did not ensure policies and procedures to prevent loss of controlled drugs were implemented. This was evident on 1 of 3 units reviewed for Medication Storage (Unit 3). Specifically, a bag containing a pair of glasses and dentures (top and bottom) were stored in the Unit 3 narcotic cabinet.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice. This was evident for 2 (2nd Floor and 4th Floor) of 3 units. Specifically, 1) medications were not kept in locked compartment and were on the 2nd Floor Nursing Station, and 2) the 4th Floor medication cart contained unopened eye drops labeled with directions to refrigerate until opened.

Inspectors wroteBased on record review and staff interviews conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure adequate dental services were provided for a resident with tooth pain. This was evident for 1 (Resident #66) of 2 reviewed for Dental out of 27 sampled residents. Specifically, Resident #66 had tooth pain that was not evaluated by the dentist in a timely manner.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that each Resident or resident representative was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, residents were not invited to quarterly care plan meetings. This was evident for 1 of 2 residents reviewed for Care Plan and 1 of 1 resident reviewed for Dental out of a sample of 24 residents. (Resident #42 & Resident #1)

Inspectors wroteBased on observations and interviews conducted during the Recertification survey, the facility did not ensure that a safe, clean, comfortable, and homelike environment was maintained. Specifically, a resident's room was observed on multiple occasions to be cluttered with food items, plastic utensils and clothing strewn on the window sills, overbed table, closet, and floor. This was observed during environmental observations on 1 of 3 units. (Unit 2)

Inspectors wroteBased on interviews and record review conducted during a Recertification survey and Complaint investigation (NY 00264258) the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were 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. Specifically, the facility did not report the self-inflicted injury of a resident to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 1 of 4 residents reviewed for Accidents out of a sample of 24 residents. (Resident #323).

Inspectors wroteBased on record review and staff interview during the recertification and abbreviated survey, the facility did not ensure that a person centered comprehensive care plan was developed and implemented to address the resident's medical needs. Specifically, there was no care plan developed to address the use of psychotropic medications. This was evident for 1 of 5 residents reviewed for Unnecessary Medication out of a sample of 24 residents. (Resident #40) The finding is: The facility policy and procedure Comprehensive Care Plan revised on 9/21/21 documented that a written comprehensive care plan will be developed and implemented for each resident in conjunction with the resident and the resident's representative. An individual comprehensive care plan will be maintained within the medical record of each resident at the facility. [...]

Inspectors wroteBased on interviews and record review conducted during a Recertification survey and Complaint investigation (NY00264258) the facility did not ensure that a resident received adequate supervision to prevent accidents. Specifically, a resident was observed sitting in their wheelchair in the back courtyard of the facility, unsupervised at night, with injury to wrists, abdomen, and inner thigh. This was evident for 1 out of 4 residents reviewed for Accidents out of a sample of 24. (Resident #323)

Inspectors wroteBased on observations, and staff interviews conducted during the Recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, 1) oxygen tubing was observed touching the floor on multiple occasions, and 2) residents were observed on the unit sitting in less than 6 feet apart from each other and were not wearing face masks. This was evident on 1 out of 3 units observed for infection control. (Unit 4)