Bushwick Center for Rehabilitation and Health Care

Inspectors wroteBased on record review and interviews conducted during the Recertification from 06/16/2025 to 06/24/2025, the facility did not ensure physician's order for code status matched the Medical Orders for Life-Sustaining Treatment form in the medical record. This was evident for 1 (Resident #230) of 1 resident reviewed for Death out of a sample of 38 residents. Specifically, the Physician Order in the electronic health record documented Resident #230's code status as full code and the Medical Orders for Life-Sustaining Treatment form documented Do Not Attempt Resuscitation and Do Not Intubate for Resident #230.

Inspectors wroteBased on record review and staff interviews conducted during a Recertification survey from 06/16/2025 to 06/24/2025, the facility did not ensure that the baseline care plan was developed and implemented within 48 hours of admission. This was evident for 2 (Resident #155 and #202) of 6 residents reviewed for Care Plan out of 38 sampled residents.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey from 06/16/2025 to 06/24/2025, 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 #147) of 4 residents reviewed for Pressure Ulcer/Injury out of an investigative sample of 38 residents. Specifically, during a wound care observation for Resident #147, Licensed Practical Nurse #5 did not change gloves and sanitize hands after cleaning wound and before applying the treatment and clean dressing to the wound.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 06/16/2025 to 06/24/2025, the facility did not ensure timely completion of each resident's quarterly review assessments. This was evident for 28 (Residents #105, #151, #6, #196, #123, #43, #134, #87, #201, #62, #199, #97, #158, #171, #197,#179, #60, #3, #94, #34, #184, #55, #93, #21, #4, #120, #27 and #181) of 28 residents reviewed during the Resident Assessment Facility Task. Specifically, the resident's Quarterly Minimum Data Set assessments were not completed within 14 days of the Assessment Reference Date.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 06/16/2025 to 06/24/2025, the facility did not ensure that a comprehensive assessment of a resident was conducted in accordance within the required timeframes. This was evident for 12 (Residents # 151, #134, #179, #4, #34, #62, #151, #120, #27, #97, #158, and #43) out of 28 residents reviewed during the Resident Assessment Facility Task. Specifically, the Admission, Annual and Significant Change assessments were not completed within 14 days of the Assessment Reference Date.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 06/16/2025 to 06/23/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident for 7 (Residents #6, #134, #123, #97, #181, 105 and 34 ) out of 28 residents reviewed for the during the Resident Assessment Facility Task. Specifically, Residents #6, #134, #123, #97, #181, #105 and #34's Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed.

Inspectors wroteBased on interview and record review conducted during an Abbreviated Survey (NY00377880), on the facility ), 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 two (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 of the facility and to other officials (including to the State Survey Agency). This was evident for one (1) out of seven (7) residents (Resident #5) reviewed for falls. [...]

Inspectors wroteBased on interview and record review conducted during an Abbreviated Survey (NY00377880), the facility failed to investigate a fall accident that had resulted in injuries. This was evident for one (1) out of seven (7) residents (Resident #5) reviewed for falls. Specifically, on [DATE] at 10:30 AM Licensed Practical Nurse #1 observed Resident #5 lying face down on the floor next to their bed unresponsive, and without vital signs. Resident #5 also had a hematoma to their forehead. cardiopulmonary resuscitation was initiated and 911 was called. Resident #5 was pronounced at 11:16 AM by the Emergency Medical Team. Registered Nurse Supervisor #1 did not investigate the unwitnessed fall and injury to rule out care plan violation.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 7/31/2023 to 8/7/2023, the facility did not ensure food was prepared in accordance with professional standards of food safety. This was evident during the Kitchen observation. Specifically, staff were observed not performing hand hygiene during food preparation.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification and Complaint (NY00317743) Survey from 07/31/2023 thru 08/07/2023, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 4 Units (Units 2N, 3N, 4L, and 4N) of 6 Units. This was evident during environmental observation. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that the comprehensive care plans (CCP) were reviewed and/or revised after each assessment and as needed. This was evident for 2 (Resident #13 and #47) of 38 total sampled residents. Specifically, 1) Resident #13's CCP related to risk for infection related to indwelling catheter, constipation related to bowel obstruction, alteration in physical function related to traumatic spinal cord injury, paraplegia, bladder spasm, ostomy appliance related to bowel obstruction, and impaired gastrointestinal function related to constipation were not reviewed upon assessment, and 2) Resident #47's CCP related to alteration in physical function, and bowel incontinence related to Cerebrovascular Accident (CVA) with hemiparesis were not reviewed upon assessment.

Inspectors wroteBased on observations interview and record review, during a recertification survey on 07/31/2023- 08/07/2023 the facility did not ensure that services provided met professional standards of practice. This was evident for 2 (Resident #190 and #89) of 2 residents reviewed for feeding tube. Specifically, 1) Gastrostomy Tube (GT) placement and residuals were not checked prior to the administration of GT medications for Resident #190, and 2) Gastrostomy Tube (GT) placement and residuals were not checked prior to the administration of GT medications for Resident #89.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification and Complaint survey from 07/31/2023 through 08/07/2023, the facility did not ensure residents were adequately supervised to prevent smoking accidents. This was evidenced for 3 of 3 residents reviewed for Smoking (Resident #s 61, 71 and 163). Specifically, 1) Resident #71 was observed smoking unsupervised, 2) Resident #163 was observed smoking unsupervised, and 3) Resident #61 was observed smoking unsupervised.

Inspectors wroteBased on observation, record review, and staff interview conducted during the recertification survey, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident for the lobby and 4 (2N, 2L, 4N, and 4L) of 6 units. Specifically, flies were observed in the lobby and on the 2nd and 4th floors. The finding is: The following observations were made on the 2nd and 4th floor: On 07/31/2023 at 10:19 AM, a fly flying in room [ROOM NUMBER]. On 07/31/2023 at 02:28 PM, 1 fly noted flying in room [ROOM NUMBER] On 08/02/2023 at 09:51 AM, 1 fly flying by nurses' station on 4L unit. On 08/02/2023 at 10:35 AM, 1 flying nurses station landing on the shelf for the medical records on top edge. On 08/02/2023 at 10:43 AM, 1 dead insect on the floor in the middle by the lobby desk. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 07/31/2023 to 08/07/2023, the facility did not ensure privacy and confidentiality of the residents' medical information was maintained. This was evident on two (Unit 4L and Unit 3L) of 6 Units and for 2 (Resident # 24 and Resident # 190) of 38 total sampled residents. Specifically, 1.) Licensed Practical Nurse (LPN) #2 left a computer screen with Resident #24's medical information open to public view, and 2.) Resident #190's room door was left open, and the resident was in public view during a Gastrostomy Tube (GT) medication administration.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 7/31/2023 to 8/7/2023, the facility did not ensure person-centered care plans (CCP) with measurable goals, time frames and interventions were developed to address a resident's concerns. This was evident for 1 (Resident #61) of 5 residents reviewed for accidents. Specifically, a CCP related to smoking was not developed and implemented for Resident #61, a smoker.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification from 7/31/2023 to 8/7/2023, the facility did not ensure a resident received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was evident for 1 (Resident #202) of 8 residents reviewed for Activities of Daily Living (ADL), out of an investigative sample to 38 residents. Specifically, Resident #202 was observed with unkempt, disheveled, matted hair.

Inspectors wrote2.) During observation of the Unit 4L medication pass on 08/02/2023 at 8:41 AM, Licensed Practical Nurse (LPN) #2 entered Resident #24's room and had their back to the medication cart while 3 blister packs of medication were left unattended on top of the cart: Lithium 300 milligram (mg) give 1 by mouth twice a day; Perphenazine 2 mg by mouth 3 times a day and Plavix 75 mg by mouth daily. LPN #2 was interviewed on 08/02/2023 at 8:47 AM and stated they should not leave medications unattended on the medication cart as to avoid someone picking them up. On 08/07/2023 at 08:25 AM, the Registered Nurse (RN) Unit Manager # 1 stated they make rounds and observe the medication carts, if the nurses are performing their duties, and if the medication carts are left unattended. [...]

Inspectors wroteBased on record reviews and staff interviews conducted during the recertification and complaint (NY00269356) survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed and implemented to address concerns identified in the comprehensive assessment. Specifically, there was no documented evidence that comprehensive care plans were developed and implemented to address risk for impaired skin integrity, a diagnosis of Urinary tract infection (UTI), psychotropic medication, and behaviors. This was evident for 3 of 38 sampled residents (Resident #s 413, 93, and 14). The finding is: The facility Policy on Care Planning last date reviewed 08/2019 documented that Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey and the abbreviated survey (NY00269356), the facility did not ensure care plans were reviewed and revised. Specifically, the comprehensive care plan (CCP) for catheter was not reviewed and revised when the catheter was in place and removed, and the CCP was not reviewed and revised after a fall. This was evident for 2 of 38 sampled residents (Resident #93 and Resident #413).

Inspectors wroteBased on observation, record review, and interview during the Recertification survey, the faility did not ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not ensure that a resident with intravenous Midline catheter inserted for antibiotic administration was provided with care and services to prevent infection in the catheter site. This was evident for 1 of 3 residents reviewed for Infection/Transmission-Based Precautions out of a sample of 38 residents. (Resident #7). The finding is: [...]

Inspectors wroteBased on record review and interviews conducted during the recertification and complaint (NY00269356) survey, the facility did not ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's cliical condition demonstrates that they were unavoidable. Specifically, (1) a resident assessed as high risk for pressure ulcers was not provided with preventive skin care to prevent skin breakdown and pressure ulcers upon admission. As a result, the resident developed two moisture associated wounds and a Deep Tissue Injury (DTI). This was evident for one (1) residents out of two residents reviewed for skin conditions (Resident #413). The finding is: [...]

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, 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. Specifically, 1) Oxygen tubing, nebulizer tubing, and nebulizer masks were observed on multiple occasions touching the floor, uncovered, and improperly stored (Resident #100). 2) During medication pass the Licensed Practical Nurse (LPN) #2 did not clean and disinfect the Blood Pressure Cuff in between residents (Resident #145 and 169). This was evident for 2 of 26 residents observed for mediation pass (Resident #145 and #169) and 1 of 3 residents investigated for Respiratory care (Resident #100) out of an investigative sample of 37 residents.