Inspection Reports for
Brooklyn Gardens Nursing and Rehabilitation Center
NY, 11233
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 9, 2025
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to failure to notify a resident's representative of significant weight loss and incomplete medical record documentation.
Complaint Details
The complaint investigation revealed that the facility did not notify Resident #4's representative of significant weight loss and failed to properly document wound treatments for Resident #2, with no evidence that treatments were administered or reasons for missing documentation.
Findings
The facility failed to notify the designated representative of Resident #4's significant weight loss exceeding 5% in one month and did not ensure medical records for Resident #2 were complete and accurately documented, with multiple instances of undocumented wound treatments.
Deficiencies (2)
Failure to notify the designated representative of Resident #4's significant weight loss exceeding 5% in one month.
Failure to ensure medical records were complete and accurately documented, specifically treatment administration records for Resident #2's wound care were left blank on multiple dates.
Report Facts
Weight loss percentage: 5.79
Weight loss percentage: 6
Dates with undocumented wound treatment: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Interviewed and stated they did not notify Resident #4's representative of weight change |
| Social Worker #1 | Social Worker | Interviewed and stated dietitian was responsible to notify representative of weight change |
| Dietitian #1 | Dietitian | Interviewed and stated they should notify representative of significant weight loss and document it; no documentation found |
| Administrator | Administrator | Interviewed and confirmed facility policy to notify representative of significant weight loss |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed and stated uncertainty about undocumented wound treatments for Resident #2 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed and stated if treatment was rendered it would have been documented |
| Wound Care Doctor | Wound Care Doctor | Interviewed and stated wound treatments must be documented and improper care can cause wound deterioration |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed and stated no documentation found explaining missing treatment sign-offs |
| Director of Nursing Services | Director of Nursing Services | Interviewed and stated no complaints received about wound treatments not being given |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Dec 2, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to investigate incidents of resident-to-resident abuse and the timeliness of reporting suspected abuse, neglect, or theft at Brooklyn Gardens Nursing & Rehabilitation Center.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to protect residents from resident-to-resident abuse resulting in injury.
Failed to timely report results of investigations of alleged abuse to proper authorities within five working days.
Report Facts
Residents sampled for abuse: 7
Residents affected: 2
Incident date and time: 2025-01-14 08:10
Incident date and time: 2025-09-14 00:40
Days late for report submission: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Documented nursing note and interviewed regarding Resident #5 and Resident #7 incident. |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed regarding observations and care of Resident #5 and Resident #7. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding care and observations of Resident #5 and Resident #7. |
| Medical Doctor #2 | Medical Doctor | Documented medical progress note on Resident #5's injuries. |
| Director of Nursing | Director of Nursing | Interviewed regarding monitoring and care plans for involved residents and reporting responsibilities. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Informed Director of Nursing and Administrator about the incident involving Resident #3 on 09/14/2025. |
| Administrator | Administrator | Responsible for reporting incidents and submitting five-day reports to the New York State Department of Health. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: May 29, 2025
Visit Reason
Inspection found multiple standard health and life safety code deficiencies related to food sanitation, infection control, IV fluids, resident rights, emergency planning, fire safety equipment, and sprinkler system maintenance. All deficiencies were corrected by July 2025.
Findings
Inspection found multiple standard health and life safety code deficiencies related to food sanitation, infection control, IV fluids, resident rights, emergency planning, fire safety equipment, and sprinkler system maintenance. All deficiencies were corrected by July 2025.
Deficiencies (7)
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Parenteral/iv fluids
Right to survey results/advocate agency info
Develop ep plan, review and update annually
Portable fire extinguishers
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 29, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 05/21/2025 to 05/29/2025 to assess compliance with regulatory requirements for Brooklyn Gardens Nursing & Rehabilitation Center.
Findings
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.
Deficiencies (4)
Failure to ensure notice of availability of survey results were posted in prominent and accessible areas of the facility.
Failure to ensure parenteral fluids were administered consistent with professional standards, including administration of expired intravenous fluids and incomplete physician orders for IV hydration.
Dietary staff observed with visible facial hair not properly covered while handling and preparing food, violating infection control standards.
Failure to maintain infection control protocol during medication administration, including failure to perform hand hygiene and don appropriate PPE.
Report Facts
Residents in Resident Council meeting: 19
Duration of survey: 9
IV infusion rate: 45
Number of residents reviewed for hydration: 3
Number of residents affected by IV fluid deficiency: 2
Number of nurses observed for infection control: 5
Number of nurses failing infection control: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Failed to perform hand hygiene and don appropriate PPE during medication administration |
| Registered Nurse #1 | Unit Manager | Entered IV hydration order and inserted peripheral access for Resident #37 |
| Registered Nurse #3 | Registered Nurse | Reinserted Resident #482's peripheral intravenous catheter but did not date the insertion site dressing |
| Registered Nurse #7 | Licensed Nurse | Entered Resident #482's physician's order and noted missing dose/frequency |
| Registered Nurse #8 | Nursing Supervisor | Observed Resident #482's undated peripheral intravenous dressing |
| Director of Nursing | Director of Nursing | Provided statements on nursing responsibilities and infection control education |
| Administrator | Administrator | Interviewed regarding missing signage for survey results |
| Recreation Director | Recreation Director | Interviewed regarding lack of discussion and signage of survey results |
| Food Service Supervisor | Food Service Supervisor | Stated dietary staff with facial hair must wear beard guards |
| Food Service Director | Food Service Director | Stated kitchen uniform requirements including hair restraint and beard guard |
| Attending Physician #1 | Attending Physician | Noted incomplete intravenous orders for Resident #482 |
| Medical Director | Medical Director | Stated medical providers must review and sign orders for accuracy and completeness |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Provided information on infection prevention education and orientation |
| Director of Nursing/Infection Preventionist | Director of Nursing/Infection Preventionist | Interviewed about infection control education and signage for enhanced barrier precautions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
One standard health citation for accident hazards and supervision was found and corrected by November 2024.
Findings
One standard health citation for accident hazards and supervision was found and corrected by November 2024.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate an elopement incident involving Resident #1 who left the facility unsupervised.
Findings
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.
Deficiencies (1)
Failure to ensure adequate supervision to prevent elopement of Resident #1.
Report Facts
Residents sampled for elopement: 16
Residents affected: 1
Date of elopement: Nov 2, 2024
Date resident found: Nov 4, 2024
Date security guards terminated: Nov 3, 2024
Date of corrective in-service: Nov 2, 2024
Date of policy revision: Nov 11, 2024
Date of resident readmission: Nov 12, 2024
Date elopement care plan implemented: Nov 12, 2024
Date elopement drill: Nov 15, 2024
Date audit tool developed: Nov 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Documented resident missing, provided interview statements about monitoring and elopement event. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Last saw Resident #1 before elopement and provided interview statements. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Reported last seeing Resident #1 and signed monitoring sheet indicating resident off unit. |
| Director of Nursing | Director of Nursing | Investigated elopement incident, provided interview statements, and oversaw corrective actions. |
| Administrator | Administrator | Provided interview statements regarding elopement awareness, security guard training, and terminations. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Oct 27, 2023
Visit Reason
Multiple standard health citations related to care plan timing, investigation and reporting of violations were found and corrected by December 2023.
Findings
Multiple standard health citations related to care plan timing, investigation and reporting of violations were found and corrected by December 2023.
Deficiencies (3)
Care plan timing and revision
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Oct 27, 2023
Visit Reason
The inspection was conducted as an Abbreviated Survey to investigate allegations of abuse involving Resident #1, specifically regarding a Certified Nursing Assistant's conduct and the facility's response to the allegation.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Report Facts
Residents sampled for abuse: 3
Residents affected: 1
Time delay in reporting abuse (hours): 26.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Documented Resident #1's report of abuse and notified ADON |
| Assistant Director of Nursing | Assistant Director of Nursing | Conducted investigation, interviewed residents, removed CNA #1 from schedule pending investigation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Alleged to have hit Resident #1 with a bed sheet |
| Administrator | Administrator | Interviewed regarding reporting requirements and timing |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan update requirements |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Jun 29, 2023
Visit Reason
Numerous standard health and life safety code citations were found including baseline care plan, drug regimen review, quality of care, resident records, environment, combustible decorations, electrical systems, emergency lighting, means of egress, fire extinguishers, sprinkler system, and smoke barriers. All were corrected by late June to mid August 2023.
Findings
Numerous standard health and life safety code citations were found including baseline care plan, drug regimen review, quality of care, resident records, environment, combustible decorations, electrical systems, emergency lighting, means of egress, fire extinguishers, sprinkler system, and smoke barriers. All were corrected by late June to mid August 2023.
Deficiencies (15)
Baseline care plan
Drug regimen review, report irregular, act on
Quality of care
Resident records - identifiable information
Services provided meet professional standards
Safe/clean/comfortable/homelike environment
Combustible decorations
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Emergency lighting
Illumination of means of egress
Means of egress - general
Portable fire extinguishers
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Abbreviated Survey
Deficiencies: 5
Date: Jun 29, 2023
Visit Reason
The inspection was an abbreviated survey conducted to assess compliance with regulatory requirements related to resident care, treatment, and medication administration.
Findings
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.
Deficiencies (5)
Failed to develop a baseline care plan within 48 hours of admission and did not provide a written summary to the resident.
Failed to ensure services met professional standards of quality; Vancomycin trough levels were not reviewed by nursing or medical staff.
Failed to provide treatment and care according to orders; missed Vancomycin doses and delayed PICC line dressing changes without notifying the physician.
Failed to perform a monthly drug regimen review adequately; Vancomycin orders lacked a future end date despite pharmacist recommendations.
Failed to maintain complete and accurate clinical records; treatment orders were not transcribed to the electronic Treatment Administration Record and were not signed for.
Report Facts
Residents sampled: 3
Vancomycin doses missed: 2
PICC line dressing change delay: 6
Vancomycin trough levels: 2
Vancomycin trough lab results: 5
Vancomycin trough lab results: 7.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Stated IDT responsible for baseline care plan completion and nursing supervisor responsible for providing copy to resident |
| Director of Nursing | Director of Nursing | Stated nursing supervisors must ensure baseline care plan completion within 48 hours and copy provided to resident |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Unaware of Vancomycin trough results and stated lab usually calls with abnormal results |
| Registered Nurse #1 | Registered Nurse | Reported missed Vancomycin doses and PICC line dressing changes, did not notify MD or document reasons |
| Medical Doctor #1 | Medical Doctor | Ordered Vancomycin trough levels, was not notified of results or missed doses, reviewed and agreed with pharmacist DRR recommendations |
| Assistant Director of Nursing | Assistant Director of Nursing | Explained lab results process and stated treatment orders should have schedules to transcribe to eTAR |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Signed eTAR for wound care but signature not found |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Performed wound dressing change and signed eTAR but signature not found |
| Wound Care Coordinator | Wound Care Coordinator | Entered wound care order but forgot to put schedule, causing order not to transcribe to eTAR |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: May 16, 2023
Visit Reason
Multiple standard health citations related to care planning, food sanitation, infection control, drug labeling, reporting violations, and environment were found and corrected by June 2023. Life safety code citations included combustible decorations and electrical equipment issues.
Findings
Multiple standard health citations related to care planning, food sanitation, infection control, drug labeling, reporting violations, and environment were found and corrected by June 2023. Life safety code citations included combustible decorations and electrical equipment issues.
Deficiencies (9)
Care plan timing and revision
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Label/store drugs and biologicals
Reporting of alleged violations
Safe/clean/comfortable/homelike environment
Combustible decorations
Electrical equipment - testing and maintenanc
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 16, 2023
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey from 05/09/2023 through 05/16/2023 to investigate allegations of abuse and to review compliance with care plan requirements.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to timely report suspected abuse involving Resident #380 to the NYSDOH within 2 hours of the allegation.
Failure to review and revise Resident #4's Comprehensive Care Plan to reflect current wound care treatment for venous and arterial ulcers.
Report Facts
Residents reviewed for abuse: 4
Total sampled residents: 38
Residents reviewed for pressure ulcers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nursing Assistant | Named in allegation of rough handling of Resident #380 |
| CNA #6 | Certified Nursing Assistant | Named in allegation of rough handling of Resident #380 |
| Director of Nursing | Director of Nursing (DNS) | Interviewed regarding abuse reporting and care plan deficiencies |
| Administrator | Administrator | Interviewed regarding abuse reporting |
| LPN #7 | Licensed Practical Nurse | Observed providing wound care to Resident #4 |
| LPN #6 | Licensed Practical Nurse | Interviewed about care plan completion responsibilities |
| Director of Nursing | Director of Nursing (DON) | Interviewed during QAPI about care plan responsibilities |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 16, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 05/09/2023 to 05/16/2023 to assess compliance with regulatory requirements for Brooklyn Gardens Nursing & Rehabilitation Center.
Findings
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.
Deficiencies (6)
Resident wheelchairs were in disrepair with missing or broken armrests padded with gauze and tape.
Maintenance Logbook did not document repair requests for wheelchair armrests for Residents #67 and #47.
Incomplete comprehensive care plans for Residents #190, #86, and #47 related to wandering, seizure disorder, and behavior respectively.
Emergency medication box on 6th floor was unlocked and missing tamper proof seal.
Expired honey thickened orange juice and multiple expired enteral feeding bottles were found in dry and emergency food storage areas.
Blood pressure cuff was used on multiple residents without sanitizing between uses, risking infection transmission.
Report Facts
Residents sampled: 38
Units observed: 6
Expired orange juice boxes: 3
Expired enteral feeding bottles: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Observed using blood pressure cuff on multiple residents without sanitizing between uses; interviewed about infection control practices |
| Licensed Practical Nurse #8 | LPN | Interviewed regarding wheelchair repair reporting and resident behaviors |
| Licensed Practical Nurse #4 | LPN | Interviewed about Resident #190's wandering and elopement risk |
| Licensed Practical Nurse #6 | LPN | Interviewed about responsibility for completing care plans |
| Licensed Practical Nurse #1 | LPN | Interviewed about emergency medication box sealing and checks |
| Certified Nursing Assistant #3 | CNA | Interviewed about reporting broken equipment |
| Certified Nursing Assistant #4 | CNA | Interviewed about Resident #47's aggressive behavior |
| Director of Nursing Services | DNS | Interviewed about care plan initiation and infection control |
| Director of Nursing | DON | Interviewed about emergency box seals and infection control practices |
| Registered Nurse Supervisor | RN Supervisor | Interviewed about emergency box checks and care plan initiation |
| Dietary Associate | Interviewed about food storage and expiration date checks | |
| Food Service Supervisor | Interviewed about food storage and rotation practices | |
| Acting Food Service Director | Interviewed about food expiration checks and rotation | |
| Infection Preventionist | Interviewed about infection control policies and staff training |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 23, 2022
Visit Reason
One standard health citation related to treatment/devices to maintain hearing/vision was found and corrected by January 2023.
Findings
One standard health citation related to treatment/devices to maintain hearing/vision was found and corrected by January 2023.
Deficiencies (1)
Treatment/devices to maintain hearing/vision
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 9, 2020
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory standards for nursing home care.
Findings
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.
Deficiencies (3)
Failure to notify and consult the physician when a resident's standing insulin order was withheld due to low blood glucose levels.
Failure to administer a resident's surgical wound dressing change as prescribed by physician orders.
Failure to ensure all drugs and biologicals were labeled and stored/discarded according to accepted professional principles, including expired items remaining on treatment carts.
Report Facts
Missed insulin doses: 16
Insulin administration opportunities: 62
Blood glucose readings range: 58-108 mg/dL
Wound size: 0.8
Wound size depth: 0.5
Expired medication items: 3
Treatment cart staffing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #3 | Attending Physician | Interviewed regarding lack of notification about withheld insulin doses. |
| RN #5 | Registered Nurse | Admitted withholding insulin doses without notifying supervisor or physician. |
| RNUM #1 | Registered Nurse Unit Manager | Interviewed about insulin standing orders and notification protocols. |
| LPN #2 | Licensed Practical Nurse | Reported working alone and unable to change wound dressing on 11/1/20 and 11/2/20. |
| DNS | Director of Nursing Services | Interviewed about staffing levels and wound care responsibilities. |
| RN #3 | Registered Nurse Supervisor | Supervised 5th floor and reported no notification of treatment issues on 11/2/20. |
| RN #4 | Registered Nurse | Supervised 5th floor on 11/1/20 and reported staffing and assistance observations. |
| LPN #1 | Licensed Practical Nurse | Responsible for treatment cart on 5th floor and acknowledged expired medications not removed. |
| RN #2 | Registered Nurse Covering Supervisor | Described procedures for handling expired medications. |
| LPN Charge Nurse | Licensed Practical Nurse Charge Nurse | Interviewed about treatment cart checks and expired Puracol dressing. |
Report
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