Downtown Brooklyn Nursing & Rehabilitation Center

Inspectors wroteBased on observations, record review, and interviews conducted during the onsite visit for Complaint NY00384702, it was determined that the facility failed to maintain safe and comfortable temperature levels. This was evident on four (4) of four (4) resident floors, where 55 out of 55 rooms sampled had temperatures above the Federal and State requirements in accordance with 42 CFR Part 483 and 10 NYCRR: 415.29. Specifically, room [ROOM NUMBER] was 105 degrees Fahrenheit, room [ROOM NUMBER] was 102 degrees Fahrenheit, and Resident #1 room [ROOM NUMBER] temperature reading was 96 degrees Fahrenheit. Three (3) complaints were submitted to the State Agency regarding high temperatures throughout the facility from 06/24/2025 through 06/25/2025, stating all residents were affected. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated and partial extended survey, complaint # NY00384702, it was determined that administration failed to ensure that 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 on four (4) of four (4) residents floors, where 55 out of 55 rooms sampled had temperatures above the Federal and State requirements. Specifically, on 06/25/2025 at 11:10 AM the temperature in room [ROOM NUMBER] was 105 degrees Fahrenheit, room [ROOM NUMBER] was 102 degrees Fahrenheit, and Resident #1 room [ROOM NUMBER] temperature reading was 96 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 04/03/2025 to 04/10/2025, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 (Resident #274) out of 4 residents reviewed for Respiratory Care out of 38 sampled residents. Specifically, Resident #274 was observed receiving oxygen via nasal cannula at a rate of 3 liters per minute without a Physician's order.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 1/3/2024 to 1/10/2024, the facility did not ensure that comprehensive resident assessments were completed within 14 days of the assessment reference date. This is evident for 1 of 38 total sampled residents. Specifically, Resident #226's annual Minimum Data Set assessment was not completed within 14 days.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 01/03/2024 to 01/10/2024, the facility did not ensure residents were assessed using the quarterly review instrument specified by the State every 3 months. This was evident in 3 (Residents #62, #70 and #145) of 38 total sampled residents. Specifically, the quarterly Minimum Data Set 3.0 assessments for Residents #62, #70, and #145 were not completed within 14 days of the assessment reference date.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 1/3/2023 to 1/10/2024, the facility did not ensure that Minimum Data Set 3.0 assessments were submitted and transmitted within 14 days of completion. This was evident for 4 (Residents #70, #145, #226 and #110) of 38 total sampled residents. Specifically, the Minimum Data Set 3.0 assessments for Residents #70, #145, #226, and #110 were not submitted and transmitted within 14 days of completion.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 01/03/2024 to 01/10/2024, the facility did not ensure the Minimum Data Set 3.0 assessment accurately reflected a resident's status. This was evident for 1 (Resident #244) of 38 total sampled residents. Specifically, the Minimum Data Set 3.0 assessment for Resident #244 did not document the resident's pain.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 01/03/2024 to 01/10/2024, the facility did not ensure a resident was given the appropriate language and communication services to maintain their ability to carry out activities of daily living. This was evident for 1 (Resident #244) of 5 residents reviewed for activities of daily living out of 38 total sampled residents. Specifically, language interpretation services were not used to communicate effectively with Resident #244.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 01/03/2024 to 01/10/2024, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (Resident #609) resident reviewed for activities out of 38 total sampled residents. Specifically, Resident #609 was not provided with television stations and meaningful activities in their preferred language.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 1/3/2023 to 1/10/2024, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident for 1 (2nd Floor) of 3 dining rooms. Specifically, Certified Nursing Assistant #6 was observed assisting multiple residents with hand hygiene without performing hand hygiene in between residents.

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure that residents received quarterly statements of their personal funds account. Specifically, the family member of a cognitively impaired resident was not provided with quarterly financial statements. This was evident for 1 of 1 resident reviewed for Personal Funds. (Resident #30) The finding is: The facility policy titled Establishment of Residents' Personal Incidental Allowance Fund dated 11/2017 documented financial statements of deposits or withdrawal of funds shall be issued quarterly. When a designated family member is responsible, the quarterly statements shall be mailed to them. The Social Worker (SW) shall be available to assist and direct the resident and/or family member to the Business Office when questions arise. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure that a resident was free from physical restraints. Specifically, a concave mattress was observed being used to restrict a resident with no prior history of falls from the bed. This was evident for 1 of 1 resident reviewed for Physical Restraints. (Resident #57)

Inspectors wroteBased on record reviews, and staff interviews during the recertification survey, the facility did not ensure that a resident's Comprehensive Care Plan (CCP)was person-centered and individualized. Specifically, there was no documented evidence the facility invited residents and/or their designated representative to attend interdisciplinary (IDT) CCP meetings to review and revise. This was evident for 2 of 4 residents reviewed for Care Planning. (Residents #170 and #207)

Inspectors wroteBased on observations, interviews, and record reviews during the Recertification survey, the facility did not ensure that a resident was provided with appropriate treatment and services to maintain or improve their ability to ambulate. Specifically, Resident #162 was not provided with the Unit Ambulation Program (UAP) in accordance with physician's orders. This was evident for 1 of 7 residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure a resident's environment remained free of hazards. Specifically, personal medication was found unsecured in a resident's room. This was evident for 1 of 2 residents reviewed in the area of Accidents/Hazards. (Resident #453)

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that medications were stored in locked compartments and in accordance with professional standards. Specifically, (1) medications were left in a resident's room; and, (2) the narcotics box contained items other than narcotics medication. This was evident for 1 of 36 sampled residents (Resident #108) and 1 of 5 medication rooms on 1 of 5 units observed for Medication storage task (unit 5).

Inspectors wroteBased on record review and interviews conducted during the recertification survey and complaint investigation (NY000269748), the facility did not ensure that a resident's medical record contained adequate documentation of scheduled clinic appointments. Specifically, the facility did not provide documentation for several scheduled and missed clinic appointments in the medical record of Resident #449. (1 of 34 residents in sample).

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that infection control practices were maintained for a resident receiving respiratory care. Specifically, oxygen tubing was observed on the floor on multiple occasions. This was evident for 1 of 1 residents reviewed for Respiratory Care (Resident #108).