Inspection Reports for
Saints Joachim & Anne Nursing and Rehabilitation Center
2720 Surf Avenue, Brooklyn, NY, 11224
Back to Facility Profile5 Reports
Inspection Report — Apr 22, 2025
Annual Inspection CMS
Date: Apr 22, 2025
Visit Reason
The inspection was conducted as a Recertification survey from 04/15/2025 to 04/22/2025 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in ensuring resident participation in care plan meetings, providing timely and appropriate Medicare beneficiary notifications, and accurately completing Minimum Data Set assessments reflecting residents' conditions such as wandering behavior and pressure ulcers.
Citations (3)
Resident or resident's representative were not consistently invited to participate in their care plan meetings.
Residents or their designated representatives were not provided appropriate notification at the termination of Medicare Part A benefits, including failure to use assistive devices and failure to mail notices on the same day as telephone notification.
Minimum Data Set assessments did not accurately reflect residents' status, including failure to document wandering behavior and failure to code a Stage 4 pressure ulcer.
Report Facts
Residents reviewed for Care Plan: 37
Residents reviewed for Beneficiary Notification: 37
Residents reviewed for Accidents: 5
Residents reviewed for Pressure Ulcers: 1
Benefit days remaining: 43
Benefit days remaining: 18
Pressure ulcer size: 4
Pressure ulcer size: 4
Pressure ulcer size: 0.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Unit Nurse Supervisor | Interviewed regarding Resident #116's alertness and care plan meeting invitations and Resident #127's pressure ulcer status |
| Regional Assistant Director of Social Work | Director of Social Work | Interviewed regarding care plan meeting invitations and documentation practices |
| Licensed Practical Nurse #2 | Interviewed about Resident #151's wandering behavior | |
| Certified Nursing Assistant #8 | Interviewed about Resident #151's wandering behavior and documentation | |
| Minimum Data Set Assessor #1 | Interviewed about Minimum Data Set assessment errors for Resident #127 | |
| Minimum Data Set Coordinator #2 | Interviewed about review process of Minimum Data Set assessments and errors | |
| Regional Minimum Data Set Coordinator | Interviewed about Minimum Data Set assessment scheduling and responsibilities | |
| Administrator | Interviewed about supervision of Minimum Data Set staff and beneficiary notification issues |
Inspection Report — Apr 22, 2025
State
Date: Apr 22, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2025 with deficiency and complaint history.
Complaint Details
The state logged 113 complaints about this facility; 7 led to on-site inspections. One citation resulted from those complaints.
Findings
Across 5 inspections, 3 had no citations while 2 inspections resulted in 38 total citations, including 9 standard health and 29 Life Safety Code citations. The facility had 113 complaints with 7 on-site inspections and no formal enforcement actions.
Citations (24)
Standard Health Citation — quality of care: Accuracy Of Assessments.
Standard Health Citation — quality of care: Medicaid/medicare Coverage/liability Notice.
Standard Health Citation — quality of care: Right To Participate In Planning Care.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure.
Standard Health Citation — quality of care: Care Plan Timing And Revision.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals.
Standard Health Citation — quality of care: Laboratory Services.
Standard Health Citation — quality of care: Menus Meet Resident Nds/prep In Adv/followed.
Standard Health Citation — quality of care: Resident Allergies, Preferences, Substitutes.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment.
Life Safety Code Citation — NFPA requirements: Develop Ep Plan, Review And Update Annually.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Other.
Life Safety Code Citation — NFPA requirements: Elevators.
Life Safety Code Citation — NFPA requirements: Ep Program Patient Population.
Life Safety Code Citation — NFPA requirements: Exit Signage.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Installation.
Life Safety Code Citation — NFPA requirements: Ltc And Icf/iid Sharing Plan With Patients.
Life Safety Code Citation — NFPA requirements: Policies For Evac. And Primary/alt. Comm.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrie.
Life Safety Code Citation — NFPA requirements: Subsistence Needs For Staff And Patients.
Life Safety Code Citation — NFPA requirements: Suite Separation, Hazardous Content, And Subd.
Report Facts
Inspections on page: 5
Total violations/deficiencies cited: 38
Inspections with violations: 2
Inspections without violations: 3
Total complaints: 113
On-site complaint inspections: 7
Citations issued from complaints: 1
Total enforcement actions: 0
Inspection Report — Apr 24, 2023
Complaint Investigation CMS
Date: Apr 24, 2023
Visit Reason
The inspection was conducted as a Recertification and Complaint survey to evaluate compliance with care plan development and revision requirements, triggered by a complaint regarding Resident #16's care.
Complaint Details
The complaint investigation was triggered by a report to the New York State Department of Health regarding Resident #16's hospitalization for gastrointestinal hemorrhage and multiple blood transfusions. The complaint was substantiated by findings that the resident's care plan was not updated to reflect these changes.
Findings
The facility failed to ensure that residents' comprehensive care plans (CCPs) were reviewed and revised by the interdisciplinary team after each assessment and as needed. This deficiency was identified in 3 out of 39 sampled residents, specifically related to changes in advance directives, post-hospitalization care plan updates, and elopement risk monitoring.
Citations (1)
Residents' comprehensive care plans were not reviewed and revised after changes in condition or assessments, including failure to update advance directives, anemia and GI bleed care plans, and elopement risk plans.
Report Facts
Residents sampled: 39
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Social Worker | Interviewed regarding responsibility for updating advance directive care plans |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding Resident #16's history and care planning |
| MDS Coordinator | Interviewed about care plan generation and updates | |
| DNS | Director of Nursing Services | Interviewed about care planning process and interdisciplinary team meetings |
Inspection Report — Apr 24, 2023
Annual Inspection CMS
Date: Apr 24, 2023
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements including environmental conditions, care planning, medication storage, laboratory services, and dietary services.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment with broken window blinds and stained wheelchairs. Care plans for several residents were not reviewed or revised timely after significant changes. Emergency medication boxes were found unlocked without tamper-proof seals. Laboratory services were not timely provided for ordered tests. Menus were not consistently followed, and resident food preferences and dietary restrictions were not always honored.
Citations (6)
Broken window blinds and stained wheelchairs observed on multiple floors.
Residents' comprehensive care plans were not reviewed and revised timely after assessments or changes in condition for 3 residents.
Emergency medication box in 6th floor medication room was unlocked and missing tamper proof seal.
Laboratory blood work ordered for Resident #19 was not done as ordered on two occasions.
Menus were not followed; residents received food items not matching tray tickets and preferences were not honored.
Residents did not consistently receive food accommodating allergies, intolerances, and preferences.
Report Facts
Residents reviewed for dining: 39
Residents present: 182
Residents reviewed for unnecessary medications: 5
Residents sampled for care plans: 39
Wheelchairs observed: 3
White stains on recliner seat: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Interviewed about broken window blinds on 5th floor |
| Director of Housekeeping | Interviewed about maintenance of window blinds | |
| Director of Engineering and Security | DES | Interviewed about maintenance work order system for window blinds |
| Rehabilitation Assistant | Interviewed about cleaning wheelchairs | |
| Director of Rehabilitation | DOR | Interviewed about maintenance and replacement of wheelchairs |
| Housekeeper #1 | Interviewed about cleaning windowsills and broken window blinds | |
| Social Worker #1 | SW | Interviewed about care plan updates for Advance Directives |
| Registered Nurse #2 | RN | Interviewed about care planning for Resident #16 |
| MDS Coordinator | Interviewed about care plan generation and updates | |
| Director of Nursing | DON | Interviewed about emergency medication box seals and lab follow-up |
| Licensed Practical Nurse #1 | LPN | Interviewed about emergency medication box on 6th floor |
| Registered Nurse Supervisor #3 | RN | Interviewed about emergency medication box checks |
| Registered Nurse #1 | RN | Interviewed about lab orders and missing lab requisitions |
| Registered Nurse #4 | RN | Interviewed about Resident #288 food preferences |
| Dietary Supervisor | Interviewed about food tray checks and resident preferences | |
| Food Service Director | Interviewed about tray ticket checks and menu substitutions | |
| Registered Dietician Eligible | RDE | Interviewed about resident food preferences and menu observations |
| CNA #6 | Interviewed about meal tray ticket accuracy |
Inspection Report — Sep 15, 2020
Annual Inspection CMS
Date: Sep 15, 2020
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements, focusing on the development and implementation of person-centered care plans for residents.
Findings
The facility failed to ensure that person-centered care plans with measurable goals, time frames, and interventions were developed for a resident exhibiting verbal abuse and rejection of care. The care plan was incomplete with no documented goals or interventions, despite documented behavioral issues and medication management.
Citations (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, with measurable goals and actions, specifically for a resident with behavioral symptoms including verbal abuse and rejection of care.
Report Facts
Residents reviewed for Unnecessary Medications: 6
Sample size of residents reviewed: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding resident's refusal of care and verbally aggressive behavior |
| Registered Nurse #2 | RN | Responsible for completion of MDS assessments and care plans; interviewed about incomplete behavior care plan |
| Nursing Supervisor | NS | Interviewed about care plan responsibilities and oversight |
| Director of Nursing Services | DNS | Interviewed about care plan initiation, monitoring, and system improvements |
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