Inspection Reports for
Brooklyn United Methodist Church Home
1485 Dumont Avenue, Brooklyn, NY, 11208
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
171% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Mar 14, 2025
Visit Reason
Inspection found deficiencies related to abuse reporting and notification of changes with level 2 severity; some deficiencies corrected by April 15, 2025.
Findings
Inspection found deficiencies related to abuse reporting and notification of changes with level 2 severity; some deficiencies corrected by April 15, 2025.
Deficiencies (3)
R9-10-803.J — Free from abuse and neglect
R9-10-803.J — Notify of changes (injury/decline/room, etc.)
R9-10-803.J — Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Mar 14, 2025
Visit Reason
The survey was conducted as an abbreviated survey to investigate compliance with regulatory requirements related to resident notification of condition changes, abuse prevention, and timely reporting of abuse allegations.
Findings
The facility failed to notify a resident's designated representative of a change in condition, failed to prevent abuse of a resident by a Certified Nursing Assistant, and did not report an allegation of abuse to law enforcement within the required two-hour timeframe. Corrective actions including staff re-education and termination of the involved CNA were implemented.
Deficiencies (3)
F 0580: The facility did not ensure a resident's designated representative was notified of changes in condition. Documentation showed no evidence of notification despite medical orders and assessments.
F 0600: The facility did not protect a resident from abuse when a Certified Nursing Assistant hit the resident on the shoulder after the resident threw liquid at the staff. The CNA was suspended and terminated following investigation.
F 0609: The facility failed to report suspected abuse to law enforcement within two hours as required. Notification occurred late, approximately three hours after the incident.
Report Facts
Residents affected: 1
Residents affected: 1
Certified Nursing Assistants in-serviced: 33
Licensed Practical Nurses in-serviced: 15
Registered Nurses in-serviced: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Involved in abuse incident hitting Resident #1; suspended and terminated | |
| Housekeeper #1 | Witnessed abuse incident and reported to nursing supervisor | |
| Registered Nurse Supervisor #1 | Assessed Resident #1 after abuse incident and reviewed surveillance video | |
| Licensed Practical Nurse #1 | Observed and instructed CNA #1 to stop caring for residents after abuse incident | |
| Director of Nursing | Oversaw investigation, confirmed abuse, and instructed corrective actions | |
| Administrator | Participated in investigation and confirmed policy on abuse reporting |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 10, 2025
Visit Reason
The inspection was a Recertification survey conducted from 01/02/2025 to 01/10/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to make survey results readily available to residents, improper notification of Medicare non-coverage, unsafe and unsanitary resident environment, inadequate posting of nurse staffing information, lapses in infection control practices during wound care, and failure to maintain a clean and safe nursing station and staff bathroom.
Deficiencies (6)
F 0577: The facility did not ensure survey results for the 3 preceding years were readily available to residents and visitors, and notices of availability were not posted in prominent areas.
F 0582: The facility failed to provide appropriate Medicare Part A termination notices timely and used incorrect forms for 3 residents.
F 0584: The residents' environment was not maintained in a safe, sanitary, and comfortable manner, with ceiling tiles in disrepair and wheelchairs and rooms found dirty or damaged on Unit 3.
F 0732: The facility did not post actual nursing staff numbers and hours in a location accessible to residents and visitors as required.
F 0880: Licensed Practical Nurse #2 failed to practice proper infection control and hand hygiene during wound care for Resident #76, including placing a sterile drape on a visibly soiled table and not washing hands between glove changes.
F 0921: The staff bathroom and nurse's station on Unit 3 were not maintained in a clean and safe condition, with dirty surfaces, dust, and a loose toilet seat.
Report Facts
Residents reviewed for Beneficiary Notification: 3
Residents reviewed for Pressure Ulcer: 27
Residents affected: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Named in infection control deficiency during wound care observation | |
| Director of Activities | Interviewed regarding survey results availability and postings | |
| Administrator | Interviewed regarding survey binder maintenance and Medicare notification process | |
| Director of Social Services | Interviewed regarding Medicare notification process and timing | |
| Housekeeper #2 | Interviewed regarding cleaning practices and nurse station cleanliness | |
| Director of Environmental Services | Interviewed regarding environmental maintenance and cleaning oversight | |
| Staffing Coordinator | Interviewed regarding nurse staffing posting practices | |
| Director of Nursing Services | Interviewed regarding nurse staffing postings and wound care oversight | |
| Registered Nurse Supervisor #1 | Interviewed regarding wound care supervision | |
| Assistant Director of Nursing | Infection Preventionist | Interviewed regarding wound care procedures and infection prevention |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 15, 2024
Visit Reason
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Findings
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Findings
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 6, 2024
Visit Reason
Immediate jeopardy level 4 deficiency related to accident hazards corrected by March 3, 2024.
Findings
Immediate jeopardy level 4 deficiency related to accident hazards corrected by March 3, 2024.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 6, 2024
Visit Reason
The abbreviated survey was conducted due to an incident involving a resident at risk for elopement who left the facility undetected, triggering an investigation into the facility's elopement prevention protocols.
Findings
The facility failed to ensure adequate supervision to prevent elopement of a resident with impaired cognition, resulting in immediate jeopardy to resident health or safety. The incident was attributed to human error involving staff disarming the wander alert alarm system without verifying the resident's presence, but corrective actions were implemented promptly.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, resulting in immediate jeopardy due to a resident eloping undetected. The incident involved staff disarming the wander alert alarm system without verifying the resident's presence, allowing the resident to leave the facility.
Report Facts
Residents affected: 24
Staff in-serviced: 88
Security guards in-serviced: 3
Nurses in-serviced: 13
Certified Nursing Assistants in-serviced: 30
Nurses total: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Entered code to disarm wander alert alarm system without knowing resident was present | |
| Security Guard #1 | Disarmed wander alert alarm system without verifying resident presence | |
| Director of Nursing | Attributed elopement to human error and responsible for ongoing staff in-servicing | |
| Administrator | Informed of elopement incident and reviewed surveillance footage | |
| Medical Director #1 | Attended safety committee meeting and stated incident was due to facility gap, not medical concern | |
| Registered Nurse Supervisor #1 | Alerted when resident was missing and last saw resident on unit |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Findings
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 25, 2023
Visit Reason
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Findings
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 19
Date: Sep 18, 2023
Visit Reason
The inspection was a recertification survey conducted from 9/10/2023 to 9/18/2023 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' rights to organize resident groups, inaccurate posting of Ombudsman contact information, incomplete advance directive documentation, unsafe and unclean environment, delayed reporting and investigation of abuse and accidents, untimely resident assessments, incomplete care plans, inadequate pain management, improper medication storage, insufficient staffing levels, and lack of proper supervision of licensed nurse permittees.
Deficiencies (19)
F 0565: The facility did not ensure residents had the right to organize and participate in resident groups, failing to organize Resident Council meetings regularly without staff present.
F 0574: The facility did not ensure residents were provided with correct contact information for the State Long Term Care Ombudsman; posted phone numbers were incorrect and non-functional.
F 0578: The facility did not ensure a resident's right to formulate an advance directive was respected; Resident #371's advance directive status was not updated upon readmission and communication with legal guardian was lacking.
F 0584: The facility did not ensure a safe, clean, comfortable environment; multiple environmental deficiencies were observed on the outdoor patio and 2nd, 3rd, and 4th floors including overgrown shrubs, dirty furniture, peeling paint, broken fixtures, urine odors, and unclean air conditioning units.
F 0609: The facility failed to timely report alleged abuse and investigate thoroughly; Resident #79's fall and injury were reported late and staff statements were incomplete.
F 0636: The facility did not complete Minimum Data Set (MDS) discharge assessments timely for Residents #103 and #105 after hospital discharge.
F 0656: The facility did not develop or implement comprehensive care plans for multiple residents addressing vision, dental, latent syphilis, and pain management needs.
F 0657: The facility did not review or revise care plans after assessments or incidents; Resident #79's fall risk care plan was not updated after multiple falls and interventions were not revised.
F 0684: Resident #24 was observed without ordered compression stockings; staff applied stockings but resident removed them without documentation of refusal or alternative interventions.
F 0688: Resident #371 with bilateral contractures was observed without an abduction/contraction cushion as ordered by the physician.
F 0689: Resident #79 was not adequately assessed or supervised for fall risk; environmental hazards were observed including an unlocked dental office with x-ray machine and drill, a shower room with slippery floor and no wet floor sign, and a 2nd floor window that could fully open.
F 0725: The facility was frequently short staffed, especially on weekends, with insufficient CNAs to meet resident care needs; staff reported burnout and inability to provide timely care.
F 0732: The facility did not post daily nurse staffing information in a prominent place accessible to residents and visitors; postings were near staff time clock and not on resident units.
F 0755: A plastic bag containing glasses and dentures was stored in the narcotic cabinet on Unit 3, violating medication storage policies.
F 0761: Medications were improperly stored on the 2nd floor nursing station desk accessible to the public; unopened eye drops requiring refrigeration were stored unrefrigerated on the 4th floor medication cart.
F 0791: Resident #66 had tooth pain that was not evaluated timely by a dentist; dental consults were refused or incomplete and follow-up was not documented.
F 0835: The facility employed 7 LPN Permittees and 1 RN Permittee without required application approval and did not provide documented RN supervision as required by the Office of Professions.
F 0865: The facility's Quality Assurance and Performance Improvement (QAPI) program did not use accurate or adequate data to identify quality improvement needs; previous survey deficiencies were not fully addressed in QAPI topics.
F 0921: The 2nd floor nursing station had chipped veneer, broken filing cabinets, and peeling chair arms that were not documented as needing repair or maintenance.
Report Facts
Deficiencies cited: 18
Residents reviewed: 27
Facility census: 113
Weekend CNA staffing shortfalls: 10
Weekend CNA staffing shortfalls: 11
Weekend CNA staffing shortfalls: 5
Opportunities for hourly monitoring missed: 142
Total opportunities for hourly monitoring: 432
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Permittee | Registered Nurse Permittee | Worked as RN Supervisor without required RN license and supervision |
| LPN Permittee #1 | Licensed Practical Nurse Permittee | Worked without required supervision and approval |
| LPN Permittee #2 | Licensed Practical Nurse Permittee | Worked without required supervision and approval |
| LPN Permittee #3 | Licensed Practical Nurse Permittee | Worked without required supervision and approval |
| LPN Permittee #4 | Licensed Practical Nurse Permittee | Worked without required supervision and approval |
| LPN Permittee #5 | Licensed Practical Nurse Permittee | Worked without required supervision and approval |
| LPN Permittee #6 | Licensed Practical Nurse Permittee | Worked without required supervision and approval |
| LPN Permittee #7 | Licensed Practical Nurse Permittee | Worked without required supervision and approval |
| CNA #7 | Certified Nursing Assistant | Reported staffing shortages and assisted Resident #79 after fall |
| CNA #9 | Certified Nursing Assistant | Reported Resident #24 removed compression stockings |
| RN #2 | Registered Nurse | Assessed Resident #79 after fall |
| RN #3 | Registered Nurse Supervisor | Reported Resident #66 was seen by dentist |
| LPN #4 | Licensed Practical Nurse | Observed medications left unattended and environmental issues |
| Director of Nursing | Director of Nursing | Interviewed regarding supervision of Permittees and medication storage |
| Administrator | Facility Administrator | Interviewed regarding staffing and use of Permittees |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plans and supervision of Permittees |
| Director of Housekeeping and Maintenance | Director of Housekeeping and Maintenance | Interviewed regarding environmental maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Sep 18, 2023
Visit Reason
The inspection was conducted as a recertification and complaint investigation to assess compliance with regulatory requirements related to resident safety, care, and facility conditions.
Complaint Details
The complaint investigation revealed multiple deficiencies including environmental hazards, delayed and incomplete abuse reporting and investigations, inadequate care planning and supervision, improper handling of residents post-fall, and staffing shortages impacting resident care and safety.
Findings
The facility failed to maintain a safe, clean, and comfortable environment, ensure timely reporting and thorough investigation of abuse allegations, develop and update comprehensive care plans, provide adequate nursing assessments post-fall, maintain adequate staffing levels, and ensure a safe environment free from hazards. Specific issues included environmental deficiencies, delayed abuse reporting, incomplete abuse investigations, inadequate care planning, improper resident handling post-fall, insufficient supervision to prevent falls, short staffing, and unsafe facility conditions.
Deficiencies (9)
F 0584: The facility did not ensure a safe, clean, and comfortable environment. Observations included overgrown shrubs and garbage on the outdoor patio, dirty and damaged furniture and fixtures on multiple floors, urine odors, broken AC units, and peeling paint.
F 0609: The facility failed to timely report alleged abuse and did not thoroughly investigate abuse allegations for residents #79 and #92, including delayed reporting to NYSDOH and incomplete staff interviews.
F 0610: The facility did not respond appropriately to alleged violations of abuse. Resident #171's forehead injury and Resident #79's fall were not thoroughly investigated, and staff statements were incomplete.
F 0656: The facility failed to develop and implement comprehensive care plans for 5 residents, including lack of care plans for glaucoma, dental issues, latent syphilis, and pain management.
F 0657: The facility did not review and revise comprehensive care plans quarterly or after assessments for residents #79 and #87, including failure to update pain management and fall risk care plans.
F 0658: Resident #79 was moved back to bed after a fall without prior RN assessment, violating professional standards of care.
F 0689: The facility failed to ensure residents remained free from accident hazards and provided adequate supervision to prevent accidents. Resident #79 was inadequately assessed and supervised for fall risk. Unsafe environmental conditions included a window that opened fully, an eyewash station missing equipment, an unlocked dental office with equipment, and a wet shower floor without signage.
F 0725: The facility did not provide enough nursing staff to meet resident needs, with frequent short staffing especially on weekends, confirmed by staffing data and staff interviews.
F 0921: The facility did not maintain a safe, functional, and comfortable environment. The 2nd floor nursing station had chipped veneer, broken filing cabinets, and damaged furniture. The outdoor area had overgrown grass, garbage, and standing water attracting insects.
Report Facts
Deficiencies cited: 9
Fall Risk Score: 15
Fall Risk Score: 23
Staffing shortfalls: 3
Staffing shortfalls: 1
Staffing shortfalls: 2
Staffing shortfalls: 2
Staffing shortfalls: 10
Staffing shortfalls: 11
Staffing shortfalls: 5
CNA Accountability: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Named in improper resident handling and staffing shortage findings. |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting, investigations, and staffing issues. |
| RN Permittee | Registered Nurse Supervisor | Interviewed regarding resident assessments and staffing. |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding resident injury and staffing. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding investigations and care plan updates. |
| Housekeeper #2 | Housekeeper | Interviewed regarding cleaning routines and environmental conditions. |
| Director of Housekeeping and Maintenance | Director of Housekeeping and Maintenance | Interviewed regarding maintenance and environmental conditions. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Findings
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 3, 2023
Visit Reason
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Findings
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 20, 2023
Visit Reason
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Findings
Deficiency in reporting to the national health safety network with level 2 severity; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 25, 2022
Visit Reason
The inspection was a Recertification survey and Complaint investigation to assess compliance with regulatory requirements for nursing home operations and resident care.
Complaint Details
The complaint investigation (NY 00264258) focused on allegations of abuse, neglect, and inadequate supervision. The facility failed to timely report a resident's self-inflicted injury and did not provide adequate supervision to prevent accidents, as evidenced by a resident found injured and unsupervised in the back courtyard.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, timely reporting of suspected abuse, development and implementation of comprehensive care plans, adequate supervision to prevent accidents, and infection prevention and control practices including COVID-19 protocols.
Deficiencies (6)
F 0584: The facility did not ensure a resident's room was maintained in a safe, clean, and homelike condition, with clutter including food items, plastic utensils, and clothing observed on multiple occasions.
F 0609: The facility failed to timely report a self-inflicted injury of a resident to the State Survey Agency within 2 hours as required.
F 0656: The facility did not develop and implement a comprehensive care plan addressing the use of psychotropic medications for a resident prior to the survey.
F 0657: The facility did not ensure residents or their representatives were offered the opportunity to participate in quarterly care plan meetings, including one resident not invited to dental care plan review.
F 0689: The facility failed to provide adequate supervision to prevent accidents, evidenced by a resident found unsupervised at night with self-inflicted injuries in the back courtyard.
F 0880: The facility did not maintain infection control practices, including oxygen tubing observed touching the floor and residents not wearing face masks while sitting less than 6 feet apart on the COVID-19 unit.
Report Facts
Residents tested positive for COVID-19: 22
Residents tested: 111
Residents reviewed for Accidents: 24
Residents reviewed for Unnecessary Medication: 5
Residents reviewed for Care Plan: 2
Residents reviewed for Dental: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | LPN | Interviewed regarding resident's room condition and verbal abuse |
| Certified Nursing Aide #2 | CNA | Interviewed regarding resident's room condition and verbal abuse |
| Director of Social Service | DSS | Interviewed about resident's behavior and room condition |
| Housekeeper #1 | Housekeeper | Interviewed about cleaning restrictions in resident's room |
| Director of Nursing | DON | Interviewed about reporting delays and care plan development |
| Assistant Director of Nursing | ADON | Interviewed about care plan meetings and infection control |
| Registered Nurse Supervisor #1 | RNS | Interviewed about resident accident and supervision |
| Licensed Practical Nurse #1 | LPN | Interviewed about resident accident and supervision |
| Certified Nursing Assistant #1 | CNA | Interviewed about resident accident |
| Security Guard #1 | Security Guard | Interviewed about resident accident supervision |
| Infection Control Nurse | ICN | Interviewed about infection control practices and training |
| Assistant Director of Nursing | ADON | Interviewed about infection control and resident mask compliance |
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