Inspection Reports for Bensonhurst Center for Rehabilitation & Healthcare
NY, 11214
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Capacity: 200
Deficiencies: 5
Jan 31, 2025
Visit Reason
The inspection was conducted as a Recertification survey from 01/26/2025 to 01/31/2025 to assess compliance with regulatory requirements including resident care, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide timely written transfer/discharge notices, incomplete and delayed care plans, inadequate pressure ulcer prevention care, and insufficient nursing staff coverage especially on weekends.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide timely notification to residents and representatives before transfer or discharge, including appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents or their representatives were afforded the opportunity to participate in their care planning process. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to ensure use of prescribed pressure-relieving devices. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift, with documented shortages especially on weekends. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility capacity: 200
Staffing shortages: 1
Staffing shortages: 5
Staffing shortages: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding care plan development and management |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding transfer paperwork and family notification |
| Director of Nursing | Director of Nursing | Interviewed regarding transfer procedures, care planning, and staffing |
| Administrator | Administrator | Interviewed regarding transfer/discharge notices and staffing |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan documentation and corrections |
| Rehabilitation Director | Rehabilitation Director | Interviewed regarding responsibility for Activities of Daily Living care plans |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding staffing levels and impact on care |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed and observed regarding pressure ulcer device use |
| Registered Nurse Manager #2 | Registered Nurse Manager | Interviewed regarding rounds and device monitoring |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Documented refusal of pressure ulcer device by resident |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Documented missing pressure ulcer device and education |
| Registered Nurse #4 | Registered Nurse | Observed resident with only one pressure ulcer device |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing levels and callouts |
| Social Worker #1 | Social Worker | Interviewed regarding care plan meeting invitations |
| Director of Social Services | Director of Social Services | Interviewed regarding care plan meeting attendance and invitations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 22, 2023
Visit Reason
The inspection was conducted as a Recertification/Complaint Survey from 2/14/2023 to 2/22/2023 to investigate complaints regarding inaccurate Minimum Data Set (MDS) assessments and resident participation in care planning.
Findings
The facility failed to ensure accurate MDS assessments for residents, including incorrect coding of discharge status and dialysis treatment. Additionally, the facility did not ensure residents or their representatives were invited to or participated in Comprehensive Care Plan meetings as required.
Complaint Details
The complaint investigation found that the facility did not ensure accurate MDS assessments for residents #64 and #193, and did not ensure resident #139 or their representative were invited to or participated in care plan meetings. The MDS Coordinator and staff acknowledged coding errors and lack of documentation of invitations. The Director of Nursing and Social Worker confirmed these issues during interviews.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure accurate MDS assessments, including incorrect discharge coding and dialysis status. | Level of Harm - Potential for minimal harm |
| Failure to involve residents or their representatives in developing the comprehensive care plan and making decisions about their care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents investigated for Dialysis: 3
Residents investigated for Discharge: 3
Investigative sample size: 38
Dialysis frequency: 3
Care plan meetings scheduled: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Coordinator (MDSC) | Interviewed regarding MDS assessment responsibilities and errors | |
| Registered Nurse (RN #1) | MDS assessor who acknowledged coding errors in MDS assessments | |
| Director of Nursing (DON) | Interviewed regarding resident dialysis status and MDS accuracy | |
| Registered Nurse (RN #2) | Interviewed regarding care plan meeting scheduling and invitations | |
| Social Worker (SW) | Responsible for scheduling and inviting residents/representatives to care plan meetings | |
| Director of Social Services (DSS) | Interviewed regarding care plan meeting invitations and documentation |
Inspection Report
Annual Inspection
Deficiencies: 9
Feb 19, 2020
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations and facility policies.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy during care, notification of Medicare benefit termination, maintenance of a safe and clean environment, accuracy of resident assessments, development of comprehensive care plans, physician oversight of resident care, medication storage and labeling, and food service safety practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Licensed Practical Nurse entered a resident room without knocking during medication administration, violating resident dignity and privacy. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not provide appropriate Medicare liability notice (SNFABN) to resident representative upon termination of Medicare Part A benefits. | Level of Harm - Minimal harm or potential for actual harm |
| Licensed Practical Nurse administered medications via peg tube without closing the door, compromising resident privacy. | Level of Harm - Minimal harm or potential for actual harm |
| Housekeeping and maintenance services were inadequate, with dirty wheelchairs, dusty AC units, scratched furniture, unpatched holes in walls, torn privacy curtains, and chipped floor tiles observed. | Level of Harm - Minimal harm or potential for actual harm |
| Minimum Data Set (MDS) assessments were inaccurate, failing to document tube feeding for one resident and a fall for another. | Level of Harm - Minimal harm or potential for actual harm |
| Comprehensive care plan was not developed for a resident on anticoagulant medication. | Level of Harm - Minimal harm or potential for actual harm |
| Resident with left toe wounds was not adequately supervised by a physician; wound status and treatment were not properly addressed or reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Medications and biologicals were not stored, labeled, and discarded according to professional standards; discontinued antibiotic eye ointment was kept on medication cart and expired enema products were found in medication room. | Level of Harm - Minimal harm or potential for actual harm |
| Food service safety was compromised due to failure to perform hand hygiene prior to handling food and improper cleaning of the meat slicer after use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for Beneficiary Protection Notification: 3
Residents reviewed for Resident Assessment: 12
Residents reviewed for Anticoagulant Side Effects: 1
Floors assessed for medication storage and labeling: 6
Medication expiration date: 2019
Medication cart antibiotic ointment use period: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Entered resident room without knocking during medication administration |
| RN #4 | Registered Nurse Charge Nurse | Monitors staff compliance with knocking policy |
| LPN #2 | Licensed Practical Nurse | Administered medications via peg tube without closing door |
| RN #5 | Registered Nurse Charge Nurse | Responsible for monitoring housekeeping and maintenance of wheelchairs and resident units |
| MDS Assessor | Interviewed regarding inaccurate MDS assessments | |
| Registered Dietitian | Responsible for section K of MDS, did not code tube feeding accurately | |
| RN #3 | Registered Nurse Charge Nurse | Interviewed regarding lack of anticoagulant care plan |
| RN #1 | Registered Nurse | Interviewed regarding wound care and X-ray order communication |
| Primary Care Provider | Physician | Interviewed regarding communication and review of X-ray results |
| Podiatrist | Ordered X-ray and provided wound care notes | |
| RN #6 | Registered Nurse | Interviewed regarding medication cart management |
| RN #8 | Registered Nurse | Interviewed regarding medication room expiration checks |
| DA #1 | Dietary Aide | Observed and interviewed regarding hand hygiene violations |
| DA #2 | Dietary Aide | Observed and interviewed regarding improper meat slicer cleaning |
| Director of Dietary | Interviewed regarding food safety policies and staff training |
Inspection Report
Capacity: 60
Deficiencies: 0
Inspection Report
Visit Reason
Inspection history and citations summary for Bensonhurst Center for Rehabilitation and Healthcare
Findings
No citations or enforcement actions reported from October 1, 2021 through September 30, 2025
Report Facts
Total inspections: 0
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