Inspection Reports for
Brooklyn Gardens Nursing and Rehabilitation Center

The state logged 125 complaints about this facility; 19 led to on-site inspections.

Across 15 inspections, 8 resulted in citations totaling 41, primarily standard health and Life Safety Code violations. All citations were of minor potential harm or minimal harm, with no actual harm or immediate jeopardy noted.

The abbreviated survey was complaint-related, investigating incidents involving resident-to-resident abuse between Resident #5 and Resident #7, and a separate incident involving Resident #3 assaulting Residents #1 and #2. The facility's investigation concluded no credible evidence of neglect or abuse in the first incident. The second incident involved delayed reporting of investigation results to the state.

The facility failed to prevent resident-to-resident abuse resulting in injury to one resident and failed to timely report the results of investigations of alleged abuse incidents to the New York State Department of Health within the required five working days. The facility concluded no credible evidence of neglect or abuse in one incident but delayed submission of investigation results in another.

The facility was found deficient in multiple areas including failure to post survey results notices, improper administration of intravenous fluids including use of expired fluids and incomplete physician orders, inadequate food handling and infection control practices, and failure to implement proper infection prevention protocols during medication administration.

The facility failed to ensure adequate supervision to prevent elopement, as Resident #1 exited the building past two security guards without being stopped. The investigation found no evidence of abuse or neglect. Corrective actions were implemented prior to the surveyor's onsite visit, including staff re-education, termination of security guards involved, installation of a security button, and implementation of an elopement care plan.

The visit was complaint-related, triggered by an allegation that CNA #1 was rough and hit Resident #1 with a bed sheet because the resident's TV volume was too loud. The allegation was not reported within two hours as required. The facility investigated but concluded no abuse occurred. The complaint was substantiated as the facility failed to timely report and thoroughly investigate.

The facility failed to report an allegation of abuse within the required two-hour timeframe, did not thoroughly investigate the alleged abuse, and failed to update the resident's care plan to address the issue of the TV volume that triggered the incident. The facility concluded no abuse occurred but did not implement interventions related to the resident's TV volume.

The facility failed to develop a baseline care plan within 48 hours of admission for one resident, did not ensure professional standards of quality in reviewing lab results, missed medication doses and delayed PICC line dressing changes, failed to address irregularities in drug regimen review, and did not maintain complete and accurate clinical records for treatments.

The complaint investigation found that an allegation of abuse by staff towards Resident #380 was not reported to the NYSDOH within the required 2-hour timeframe. The allegation involved rough handling by two Certified Nursing Assistants. The facility's investigation could not substantiate the abuse due to the resident's behavior. The Director of Nursing and Administrator stated the case was believed to have been reported by the Attorney General's office.

The facility failed to report an allegation of abuse involving staff towards Resident #380 to the New York State Department of Health within the required 2-hour timeframe. Additionally, the facility did not ensure that Resident #4's Comprehensive Care Plan was reviewed and revised by the interdisciplinary team to reflect current wound care treatment.

The facility was found deficient in multiple areas including maintenance of resident wheelchairs, development and implementation of comprehensive care plans for residents, proper storage and labeling of drugs and biologicals, safe food storage practices, and infection prevention and control practices. Several residents' wheelchairs were in disrepair, care plans were incomplete for certain residents, emergency medication boxes lacked tamper-proof seals, expired food items were found in storage, and infection control practices related to blood pressure cuff sanitation were not consistently followed.

The facility was found deficient in multiple areas including failure to notify and consult a physician when insulin treatment was withheld due to low blood glucose levels, failure to change a resident's surgical wound dressing as ordered, and failure to properly discard expired drugs and biologicals from treatment carts.