Brooklyn Gardens Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brooklyn, New York.
- Location
- 835 Herkimer Street, Brooklyn, New York 11233
- CMS Provider Number
- 335070
- Inspections on file
- 22
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Brooklyn Gardens Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions had physician-ordered wound care for a right medial bunion, but the treatment administration record and nursing progress notes showed numerous dates where wound care was not documented as completed. Interviews with LPNs and facility leadership revealed uncertainty about whether the care was provided, and no documentation was found to explain the omissions, contrary to facility policy requiring complete and accurate medical records.
A resident with end stage renal disease and pressure ulcers experienced a significant weight loss of over 5% in one month. Despite facility policy requiring notification, the resident's representative was not informed of this change, and no documentation of notification was found in the medical record. Staff interviews revealed confusion over who was responsible for notifying the representative.
Two residents with behavioral and cognitive challenges were involved in an altercation after one wandered into the other's room through a shared bathroom. Despite care plans and staff monitoring, the wandering resident was able to enter the room unsupervised and was physically assaulted, sustaining a lip injury. Staff interviews confirmed that both residents required close observation and redirection, but the incident occurred when staff were not present to intervene.
The facility did not submit the results of an abuse investigation to the state health department within the required five-day period after an incident where a resident struck two others, causing injuries. The DON and Administrator were aware of the reporting requirements but acknowledged the report was submitted late, with no explanation provided for the delay.
Surveyors identified that two residents received IV therapy that did not meet professional standards: one received expired IV fluids, and another had an undated IV site dressing and incomplete physician orders lacking infusion rate and site care instructions. Nursing staff failed to check expiration dates, properly document, and ensure complete orders, while oversight by the DON and medical providers was insufficient.
Dietary staff were observed handling food and utensils without properly covering facial hair, contrary to facility policy requiring beard guards for infection control. Staff interviews confirmed lapses in following the required uniform standards, and facility leadership acknowledged the expectation for all facial hair to be covered during food preparation.
An LPN failed to follow infection control protocols while administering medications to a resident with a gastrostomy tube, including not performing hand hygiene, not changing gloves after picking up a dropped medication, and not donning required PPE despite posted Enhanced Barrier Precautions. The LPN, who was newly hired and had received relevant training, did not notice the signage or available PPE supplies.
The facility did not post required notices about the availability of survey results in prominent and accessible areas, as confirmed by observations, staff interviews, and resident feedback. Residents were unaware of where to find survey results, and staff had not discussed or observed any postings regarding their availability.
A resident with moderate cognitive impairment and using a rollator walker eloped from the facility without being stopped by security guards. The resident was not identified as an elopement risk, and an elopement care plan was not in place. Surveillance footage showed the resident exiting past two security guards who failed to follow the facility's policy of checking identification and ensuring residents do not leave unescorted.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards and practices for one resident. Specifically, a resident with diagnoses including non-Alzheimer's dementia, congestive heart failure, and peripheral arterial disease had a physician's order for daily wound care to the right medial bunion. The treatment administration record and nursing progress notes showed multiple dates over a two-month period where wound care was not documented as completed, and there was no documentation explaining the omissions. The facility's policy required that all events pertaining to a resident's stay, including treatments, be documented by licensed professionals. Interviews with nursing staff and facility leadership revealed uncertainty about whether the wound care was provided on the undocumented dates. Staff members could not recall the resident or the specific treatments, and some suggested that either the wound care team performed the treatment or the resident was not present or refused care. However, there was no documentation to support these explanations. The Assistant Director of Nursing confirmed that no additional documentation could be found to clarify the missing entries, and stated that unsigned treatment administration records indicate that care was not rendered.
Failure to Notify Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the designated representative of a resident's significant weight loss, as required by its own policy and regulatory standards. The resident in question had multiple diagnoses, including end stage renal disease and stage 2 and 3 pressure ulcers. The resident experienced a weight loss of more than 5% in one month, as documented in both the weight monitoring records and dietary notes. Despite this significant change, there was no documented evidence in the medical record that the resident's representative was informed of the weight loss. Interviews with facility staff, including a registered nurse, social worker, and dietitian, revealed that each believed the responsibility for notifying the representative lay with another staff member. The dietitian confirmed that the weight loss was significant and that notification should have occurred, but upon review of the dietary notes, found no documentation of such notification. The administrator also acknowledged that notification and documentation were required in cases of significant weight change, but confirmed that this did not occur for the resident.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by an incident involving two residents with cognitive and behavioral challenges. One resident, who had severe cognitive impairment and a history of wandering and aggressive behaviors, entered another resident's room through a shared bathroom. The second resident, who had intact cognition but was known to be verbally aggressive and did not want others entering their room, responded by physically assaulting the wandering resident, resulting in an abrasion and swelling to the upper lip. Documentation showed that the care plan for the wandering resident included interventions such as staff observation during rounds, monitoring for mood changes, and keeping the resident away from peers whenever possible. Nursing instructions also noted the resident's behaviors of wandering, aggression, and resistance to care. Despite these interventions, the resident was able to access another resident's room unsupervised, leading to the altercation. Staff reported performing hourly rounding and monitoring, and both residents were known to require redirection and close observation due to their behaviors. Interviews with staff confirmed that the wandering resident was last seen in their own room shortly before the incident and that staff typically redirected them when observed wandering. The resident who committed the assault had previously expressed a desire for privacy and resistance to others entering their room. The incident occurred when staff were not present to intervene, and the facility's investigation concluded that there was no credible evidence of neglect, abuse, or mistreatment, despite the physical injury sustained.
Late Submission of Abuse Investigation Findings to State Authorities
Penalty
Summary
The facility failed to ensure that the results of all investigations into alleged abuse, neglect, exploitation, or mistreatment were reported to the administrator or their designee and to the appropriate state authorities within five working days, as required by both facility policy and state regulations. Specifically, an incident occurred in which one resident struck two other residents with a wheelchair footrest, resulting in injuries: one resident sustained an injury above the right eyebrow, and another developed a large swelling on the right arm. The facility conducted an investigation and determined that the incident did not meet the definition of abuse due to the absence of a prior pattern of aggression or clear intent to harm. However, the results of this investigation were not submitted to the New York State Department of Health within the mandated five-day period; instead, the findings were submitted three days late. The residents involved had varying medical histories, including end stage renal disease, diabetes mellitus, depression, hypertension, and cerebrovascular disease, with cognitive assessments ranging from moderately impaired to intact. Interviews with the DON and Administrator confirmed that both were aware of the reporting requirements and acknowledged the late submission of the five-day report. The Administrator could not provide a reason for the delay in submitting the investigation results to the state agency.
Deficient IV Fluid Administration and Documentation
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids in accordance with professional standards of practice for two out of three residents reviewed for hydration. In one instance, a resident with severe cognitive impairment and a dislodged gastrostomy tube was observed receiving IV fluids from a bag that was past its expiration date. The LPN who administered the IV fluids admitted to not checking the expiration date before use, and the Unit Manager was unaware that expired fluids were being administered. The DON confirmed that nurses are required to verify both the match to the physician's order and the expiration date of IV solutions before administration. In another case, a resident with intact cognition and a need for IV hydration due to diarrhea was found with an undated peripheral IV catheter dressing. The physician's order for IV hydration lacked critical details, including the infusion rate and instructions for assessment and maintenance of the IV site. There was also no documented order for the insertion of the IV line or for dressing changes. The Medication Administration Record did not specify the infusion rate, and the Treatment Administration Record lacked documentation of site inspection, assessment, or dressing changes as required by facility policy. Interviews with nursing staff and the DON revealed lapses in following established protocols, such as failing to date IV dressings and not ensuring complete and accurate physician orders for IV therapy. The attending physician and medical director both acknowledged that the orders were incomplete and not properly reviewed or signed. These deficiencies were observed during the recertification survey and were not accompanied by any corrective or follow-up actions in the report.
Failure to Ensure Proper Facial Hair Restraint During Food Handling
Penalty
Summary
During a recertification survey, it was observed that dietary staff did not consistently follow professional standards for food service safety and infection control in the kitchen. Specifically, one dietary aide was seen handling utensils and scooping watermelon while having a visible mustache and goatee without a beard cover. Another dietary aide was observed on the tray line handling various food items with their beard guard positioned below their mustache, leaving facial hair uncovered. These actions were in direct violation of the facility's policy, which requires all facial hair to be covered by a beard guard when handling food. Interviews with the involved staff revealed that one aide forgot to wear the beard cover, while the other stated they were previously instructed to only cover the bottom part of their face. Both the Food Service Supervisor and Food Service Director confirmed that the facility's uniform policy mandates the use of hair restraints and beard guards for staff with facial hair to prevent hair from contaminating food. The failure to adhere to these standards resulted in a deficiency related to food safety and infection control practices.
Failure to Follow Infection Control Protocols During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to adhere to infection control protocols during medication administration to a resident with a gastrostomy tube. The LPN did not perform hand hygiene before donning gloves to prepare medications, picked up a medication that had fallen on the floor with the same gloved hands, and continued to administer medications without changing gloves or performing hand hygiene. Additionally, the LPN did not don the required personal protective equipment (PPE) before entering the resident's room, despite signage indicating the need for Enhanced Barrier Precautions. Interviews revealed that the LPN was newly hired and had received orientation and in-service education on infection prevention, including hand hygiene and Enhanced Barrier Precautions. The LPN stated they did not notice the signage or the availability of PPE supplies near the resident's room. Facility leadership confirmed that infection control education and signage were in place and that supplies were accessible, but the LPN did not follow established protocols during the observed medication administration.
Failure to Post Survey Results Notice in Prominent Areas
Penalty
Summary
The facility failed to ensure that notices regarding the availability of survey results were posted in prominent and accessible areas, as required by both facility policy and regulatory standards. Multiple observations throughout the facility, including the main lobby, revealed that there were no posted notices indicating where survey results could be reviewed. The facility's policy specifies that such notices must be visibly posted in designated areas, but this was not adhered to during the survey period. During a Resident Council meeting, all residents in attendance reported that they did not know where to find the survey results and had not seen any notices about their availability. Additionally, review of previous Resident Council meeting minutes showed no documentation that residents were informed about the location of survey results. Interviews with staff, including the Recreation Director, confirmed that the topic had not been discussed and that no signage was observed. The Administrator acknowledged that the signage had previously been present but was not currently posted.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident, which was evident in one out of sixteen residents sampled for elopement. The incident occurred when a resident with a history of Schizophrenia Disorder and Cerebral Infarction, who was not identified as at risk for elopement, exited the facility unescorted. The resident, who had moderate cognitive impairment and used a rollator walker, was last seen on the unit at 11:00 AM. Surveillance footage showed the resident walking past two security guards without being stopped, exiting through the automatic front doors and the front gate leading to the street. The facility's policies on elopement prevention and security reception were not effectively implemented. Security Guard #1, stationed at the front desk, was observed talking to another resident and did not stop the resident from leaving. Security Guard #2, stationed at the front gate, was not paying attention and did not notice the resident leaving. The resident was not identified as an elopement risk upon admission, and an elopement care plan was not in place. The facility staff became aware of the resident's absence between 12:30 PM and 1:00 PM, and a search was initiated, but the resident was not found until later. Interviews with facility staff revealed that the security guards did not follow the facility's policy of checking identification and ensuring residents do not leave the facility unescorted. The resident was wearing an identification band, but the security guards failed to verify it. The facility's Director of Nursing and Administrator were informed of the incident, and local law enforcement was contacted. The resident was eventually found at a hospital and returned to the facility without injury.
Latest citations in New York
A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Failure to Assess and Respond to Prolonged Poor Oral Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding nutrition and hydration monitoring and response. The resident had dementia with declining mental and functional status, pulmonary venous congestion, severely impaired cognition, and required partial/moderate assistance with eating. A dietary care plan identified the resident as at risk for dehydration due to dementia and varied oral intake, with interventions to observe for signs and symptoms of dehydration and explore reasons for decreased intake. Physician orders placed the resident on a no added salt mechanical soft diet with thin liquids, later downgraded to puree solids per speech therapy. Certified Nursing Assistant (CNA) documentation showed that the resident had no documented oral intake from the morning of 03/14/2026 through early afternoon on 03/16/2026, totaling eight missed meals. CNAs reported that the resident had a history of poor appetite, combative behavior during care, and variable intake ranging from 25% to 75% of meals. For the relevant period, CNAs stated they documented 0% food consumption because the resident refused to eat, and they acknowledged offering fluids or juice but did not document fluid intake. They also stated they did not report the resident’s refusal to eat to the LPN, despite facility policy requiring staff to report poor intake and meal consumption of less than 50% to the nurse immediately. Nursing staff, including LPNs and RN supervisors, reported that they did not receive information from CNAs that the resident was not eating or drinking during the days in question. LPNs stated they would have encouraged intake and notified supervisors if they had known the resident was not eating, and they reported that they did not observe the resident as weak or less responsive during their shifts. The RN supervisors stated they did not receive reports of poor appetite or meal refusal and indicated that CNAs were expected to notify the unit nurse when a resident refused or did not eat. There was no care plan addressing the resident’s refusal of meals or poor appetite, and there was no documentation that a nurse assessed the resident for poor intake or that the physician was notified until 03/16/2026 at 3:44 PM, when the RN Supervisor assessed the resident with a change in mental status, rapid decline, weakness, lethargy, and minimal responsiveness, and noted that the resident had not been eating and was spitting up brown secretions. Only at that time was the physician contacted and medical interventions initiated. The facility’s own policy on Meal Consumption required CNAs to document intake percentages for each meal, record refusals and behaviors, and promptly report poor intake, and required nurses to review intake documentation daily, assess residents with poor intake, document interventions and outcomes, and notify the medical provider as indicated. The policy also required physician notification when intake was consistently less than 50% or when significant decline in intake was observed. Despite this, the resident’s extended period of no documented oral intake and repeated 0% meal consumption entries were not acted upon by nursing staff, and the physician was not notified until after a significant change in condition was observed. This sequence of inaction and lack of assessment and notification in the face of documented poor intake led to the cited deficiency under 10 NYCRR 415.12.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
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