Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bedford Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility was cited for failing to keep the patio gate to the public way unobstructed. During a survey, it was found that the gate was locked with a padlock, and the key was not immediately available, requiring staff to re-enter the building to retrieve it. This delay in access violated safety regulations.
Controlled medications in Unit 2 were not stored properly due to a malfunctioning lock on the cabinet, leaving them unsecured. Staff were aware of the issue but failed to relocate the medications to a secure area, and there was a lack of communication with nursing administration about the problem.
A resident with type 2 Diabetes Mellitus did not have a physician's order for their Freestyle Libre device documented upon admission, leading to an LPN administering insulin without verifying the blood sugar reading on the device. The oversight was identified during a survey, and the primary physician was unaware of the missing order until informed later.
A resident with moderately impaired cognition received insulin in a hallway without privacy, contrary to facility policy. The LPN administered the injection in a public area, despite the availability of screens to ensure privacy, as the resident was impatient and refused to go to their room.
The facility did not maintain continuous lighting in all means of egress. A manual switch in the basement storage room could disable all lights, and a ramp area leading to the public way lacked egress lighting. The Maintenance Director confirmed these issues.
The facility did not provide appropriate EXIT and NO EXIT signs in the path of egress on 2 out of 5 floors. Observations during a life safety survey revealed missing NO EXIT signs on doors to outside patios on the main and second floors, and a lack of EXIT signage in a family room with multiple doors. The Maintenance Director stated that staff are advised to put up signs where appropriate.
The facility did not ensure proper storage of oxygen tanks as per NFPA 99 standards. During a survey, it was found that oxygen tanks on floors 2 and 1 were not secured and were freely placed on the floor. The Maintenance Director confirmed advising staff to secure the tanks, highlighting a lapse in safety protocol adherence.
The facility did not ensure the soiled linen room was protected with proper fire resistive material. A life safety survey revealed a 1ft x 1ft wall cut out in the hydraulic motor room filled with pink fiberglass material, which is not an appropriate fire/smoke sealant. The Maintenance Director acknowledged the issue.
The facility did not ensure smoke barrier doors on the first floor were compliant with NFPA 101 standards, as a four-inch gap was observed between door leafs during a survey. The maintenance director acknowledged the issue.
Patio Gate Obstruction Due to Unavailable Key
Penalty
Summary
The facility failed to ensure that the patio gate leading to the public way was unobstructed, as required by safety regulations. During a life safety survey conducted over two days, it was observed that the patio on the main floor was secured with a padlock. When surveyors requested the gate to be opened, the key was not immediately available, necessitating staff to re-enter the building to retrieve it. This delay in accessing the key indicates a deficiency in maintaining an unobstructed and accessible exit path, as required by safety standards.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action A break box with the key to the gate was installed on 4/4/25 near the emergency exit for easy access in case of an emergency. II. Identification of Other Residents The facility respectfully states that residents could potentially be affected by this deficient practice. An audit of all exit areas leading to the street was conducted. No other outstanding issues were found. III. Systemic Changes Maintenance was in-serviced regarding the need for easy access to exit the building and property in an event of an emergency. A comprehensive review of all exits was done, no other issues were noted. IV. Monitoring On a monthly basis for one quarter, Director of Maintenance or designee, will check the facility exits to the public way for potential obstruction. Any outstanding issues will be reported to the Administrator and corrected immediately. On a quarterly basis, Director of Maintenance or designee, will report findings to QAPI Committee to determine if further action is required. Responsible Party: Director of Maintenance
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were stored in accordance with professional principles, as observed during a recertification survey. Specifically, in the Unit 2 medication room, controlled substances were not properly stored in a double-locked cabinet. During an observation, it was noted that the second door of the cabinet was ajar, and the lock was not functioning, leaving multiple controlled medications unsecured. The facility's policy requires controlled substances to be stored in a locked container separate from non-controlled medications, and this container must remain locked at all times except when accessed for resident medications. Interviews with staff revealed that the issue with the narcotic cabinet lock had been ongoing for several days. A Licensed Practical Nurse noticed the malfunction two days prior to the survey and reported it to maintenance and the Assistant Director of Nursing, but the issue was not resolved. The Registered Nurse and Assistant Director of Nursing both acknowledged that the medications should not have been kept in the cabinet if the locks were not working and should have been moved to a secure location. The Director of Nursing was not informed of the issue until a week later, indicating a breakdown in communication and protocol adherence regarding the storage of controlled substances.
Plan Of Correction
Plan of Correction: Approved April 8, 2025 Corrective Actions for Residents Identified All controlled substances were removed from the cabinet and locked in appropriate storage immediately on 3/14/2025. The double locked cabinet for controlled medications (substances) on Unit 2 was fixed on 3/14/25 to ensure both locks are functioning. The RNS #1, LPN #2, and LPN #3 were in-serviced on medication storage on (MONTH) 14, 2025. Residents at Risk All residents have the potential to be affected by this practice. All medication carts and storage rooms were inspected for medications and biologicals beyond their expiration date and none were found. Systemic Change The facility policy titled "Controlled Substances" was reviewed, and no revision needed. All nurses are being in-serviced on "Controlled Substances" policy and procedure. New process is being implemented for medication storage monitoring to ensure compliance (LPN to check med carts daily; Unit RN to check med rooms daily). All nurses are being in-serviced on this process by DNS. The audit tool was developed to monitor for compliance. Monitoring of Corrective Action On a weekly basis for one quarter, DNS or designee will inspect 2 med rooms and 2 med carts, to ensure compliance with controlled medication storage. Any outstanding issues will be addressed immediately. On a monthly basis, DNS or designees will report findings to Administrator. On a monthly basis, DNS or designees will report the findings to QAPI Committee. QAPI Committee to determine if further action is required. Responsible person: Director of Nursing
Failure to Document and Verify Blood Sugar Readings for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified during a recertification survey, where it was observed that a resident with a diagnosis of type 2 Diabetes Mellitus did not have a physician's order for the use of a Freestyle Libre device, which was used to monitor their blood glucose levels. The resident was admitted from the hospital with this device, but the order for its use was not documented in the facility's records. During a medication administration task, an LPN administered insulin to the resident without verifying the blood sugar level on the Freestyle Libre device, relying solely on the resident's verbal report of their blood sugar reading. Interviews with the nursing staff and the Director of Nursing revealed that the LPNs were expected to verify blood sugar readings on the device before administering insulin. The primary physician for the resident was unaware that an order for the device had not been placed initially and only rectified this after being informed of the oversight.
Plan Of Correction
Plan of Correction: Approved April 8, 2025 Corrective Actions for Residents Identified - For Resident # 40, RN reviewed the blood sugar levels; there were no negative outcomes from the deficient practice as evidenced by the stable blood sugar levels between 122 and 301. - Licensed Practical Nurse #3 was in-serviced on Medication Administration with an emphasis on the verification of blood sugar prior to Insulin injection on (MONTH) 14, 2025. - Registered Nurse # 3 was in-serviced on Medication Order Reconciliation policy on (MONTH) 14, 2025. - The order for Continuous Glucose Monitoring device was reviewed and revised on (MONTH) 14, 2025. Residents At Risk - All residents receiving Insulin injections have the potential to be affected by this practice. - An audit of all residents receiving Insulin injections admitted in the past 3 months is being done to ensure all orders are reconciled and accurate. Any outstanding findings will be addressed immediately. Systemic Changes - The policy and Procedure “Medication Order Reconciliation” was reviewed by DNS on (MONTH) 14, 2025, and no revision needed. - The policy and procedure titled “Medication Orders” was reviewed by DNS on (MONTH) 14, 2025, and no revision needed. - All nurses are being in-serviced by the ADNS on “Medication Order Reconciliation” and “Medication Orders” Policies. - All nurses are being in-serviced by the ADNS on “Personal Glucose Monitoring Devices and Continuous Glucose Monitoring (CGM) System” policy and procedures. - “Use of Personal Glucose Monitoring Devices and Continuous Glucose Monitoring (CGM) System” policy and procedure was developed and is being implemented. The procedure includes specific steps for nurses to follow to ensure the blood glucose readings are verified prior to Insulin administration. - The medication administration competency observation was revised; Continuous Glucose Monitoring System was added. - The audit tool was developed for monitoring compliance. Monitoring Of Corrective Actions - On a weekly basis for one quarter, ADNS or designee will audit new admission/re-admission orders [REDACTED]. - Any outstanding issues will be addressed immediately and reported to DNS. - On a weekly basis for one quarter, ADNS or designee will interview and observe, when applicable, 2-4 nurses for competency with Continuous Glucose Monitoring System. - On a monthly basis, ADNS or designee will report findings to DNS. - On a monthly basis, DNS or designee will report findings to Administrator. - On a quarterly basis, DNS or designee will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. Responsible party: Director of Nursing
Failure to Ensure Resident Privacy During Insulin Administration
Penalty
Summary
The facility failed to ensure that each resident was treated with respect and dignity, as evidenced by the administration of insulin to a resident in a public area without privacy. Specifically, a Licensed Practical Nurse (LPN) administered insulin to a resident while they were seated in the hallway, where other residents were walking by, without providing any form of privacy. The facility's policy on dignity, which mandates the protection of resident privacy during treatment procedures, was not adhered to in this instance. The resident involved had moderately impaired cognition and required insulin injections daily. During the medication administration task, the LPN asked the resident if they had checked their blood sugar and, upon confirmation, proceeded to administer the insulin in the hallway. Interviews with the LPN and the Resident Nurse Manager revealed that the resident often refused to go to their room for insulin administration due to impatience. Despite this, the Director of Nursing stated that privacy should have been ensured, even in the hallway, by using available screens.
Plan Of Correction
Plan of Correction: Approved April 9, 2025 Corrective Actions for Residents Identified ò For Resident # 40 there were no negative outcomes from the deficient practice as evidenced by vocalization and observation. ò Licensed Practical Nurse #3 was in-serviced on resident’s dignity on (MONTH) 14, 2025. Residents At Risk ò All residents have the potential to be affected by this practice. ò All nurses were assessed for competency. DNS and designee observed random medication administration to ensure compliance. Systemic Changes ò The policy and Procedure “Quality of Life-Dignity” was reviewed, and no revision needed. ò All nurses are being in-serviced on “Quality of Life-Dignity” Policy and Procedure, with emphasis on privacy during medication administration. ò The medication administration competency observation was revised; dignity during med pass was added. ò The audit tool was developed for monitoring compliance. Monitoring Of Corrective Actions ò On a weekly basis for one quarter, ADNS or designee will observe 1-3 nurses during medication pass to ensure resident’s dignity is maintained. ò Any outstanding issues will be addressed immediately and reported to DNS. ò On a monthly basis, ADNS or designee will report findings to DNS. ò On a monthly basis, DNS or designee will report findings to Administrator. ò On a quarterly basis, DNS or designee will report findings to QAPI Committee. ò QAPI Committee to determine if further action is required. Responsible person: Director of nursing
Deficiency in Egress Lighting Maintenance
Penalty
Summary
The facility failed to ensure that lighting in all means of egress was continuously maintained, as required by safety regulations. During a life safety survey conducted over two days, it was observed that a manual switch on the wall in the basement storage room (B23) could disable all lights, leaving the area in total darkness. Additionally, a ramp area leading to the public way on the exterior of the facility, measuring approximately 20-30 feet, was found to lack egress lighting. These deficiencies were confirmed during an interview with the Maintenance Director, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action Maintenance removed the light switch and replaced it with a metal plate for the basement in order to prevent the light from being turned off. Lights were added to the ramp area to ensure continuous illumination. II. Identification of Other Residents The facility respectfully states that residents could potentially be affected by this deficient practice. An audit of facility lighting in all means of egress was conducted. No outstanding issues were found. III. Systemic Changes The Maintenance department was in-serviced and educated about Illumination of Means of Egress. Continuous illumination was added to the monthly environmental rounds. IV. QA Monitoring The facility will conduct a review of all lighting by means of egress on a quarterly basis. This report will be done by the Director of Maintenance or his designee and submitted to the QA committee for review. On a quarterly basis, the Director of Maintenance or designee will report findings to the QAPI Committee to determine if further action is required. Responsible Party: Director of Maintenance
Inadequate Egress Signage
Penalty
Summary
The facility failed to ensure that appropriate EXIT and NO EXIT signs were provided in the path of egress on 2 out of 5 floors. During a life safety survey conducted over two days, it was observed that on the main floor, a door leading to the outside patio lacked a NO EXIT sign, and a family room with multiple doors did not have EXIT signage. Additionally, on the second floor, the door to the outside patio was also missing a NO EXIT sign. The Maintenance Director mentioned that staff are advised to put up signs where appropriate, indicating a lapse in ensuring compliance with signage requirements.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action A "no exit" sign was posted immediately on the patio door and on the 2nd floor patio. Exit signs were posted in the family room. All signs were added the day it was pointed out on 3/12. II. Identification of Other Residents The facility respectfully states that residents could potentially be affected by this deficient practice. An audit of all areas that require exit and directional signs to be displayed was conducted. No outstanding issues were noted. III. Systemic Changes Maintenance was in-serviced regarding proper signage that needs to be posted around the building and has done a comprehensive review of all signage posted in the building. IV. QA Monitoring The facility will conduct an inspection of all signage on a quarterly basis. This report will be done by the Director of Maintenance or his designee and submitted to the QA committee for review. QAPI committee to determine if further action is required. Responsible Party: Director of Maintenance
Improper Storage of Oxygen Tanks
Penalty
Summary
The facility failed to ensure proper storage of oxygen tanks in accordance with NFPA 99 standards. During a life safety survey conducted on March 12 and 13, 2025, it was observed that oxygen closets on floors 2 and 1 contained single oxygen tanks that were not secured and were freely placed on the concrete floor. This deficiency was noted on 2 out of 5 floors. In an interview, the Maintenance Director acknowledged advising staff to secure all oxygen tanks, indicating a lapse in adherence to safety protocols.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action The cylinders were placed in the proper holders during the survey after it was pointed out. All facility staff were educated on the safe storing of Gas Equipment. II. Identification of Other Residents The facility respectfully states that residents could potentially be affected by this deficient practice. III. Systemic Changes All staff were in-serviced and educated about safe storing of Gas Equipment. The maintenance department will check and track daily compliance, using a daily tracking sheet. IV. QA Monitoring The Director of Maintenance will review all logs on a quarterly basis. This report will be done by the Director of Maintenance or his designee and submitted to the QA committee for review. QAPI committee to determine if further action is required. Responsible Party: Director of Maintenance and Director of Nursing
Improper Fire Resistive Material in Soiled Linen Room
Penalty
Summary
The facility failed to ensure that the soiled linen room was protected with proper fire resistive material. During a life safety survey conducted over two days, a penetration in the hydraulic motor room located in the basement was observed. This penetration consisted of a 1ft x 1ft area wall cut out filled with pink fiberglass material, which is not an appropriate fire/smoke sealant. The Maintenance Director acknowledged the issue and indicated that the material would be removed and replaced with suitable fire/smoke sealant.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action Maintenance filled the hole on 3/28/25 with concrete. II. Identification of Other Residents The facility respectfully states that residents could potentially be affected by this deficient practice. The maintenance department inspected the entire building to ensure compliance. No outstanding issues were noted. III. Systemic Changes The Maintenance department was in-serviced about Hazardous Areas - Enclosure. Maintenance will inspect all areas after any construction work is done. Responsible Party: Director of Maintenance
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to ensure that smoke barrier doors were designed to resist fire and smoke in accordance with NFPA 101 standards. During a life safety survey conducted over two days, it was observed that on the first floor, there was a four-inch gap between the door leafs of the smoke barrier doors when tested manually. This deficiency was identified through both observation and an interview with the maintenance director, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action The doors were adjusted on 4/1/25 and tested to ensure compliance. II. Identification of Other Residents The facility respectfully states that residents could potentially be affected by this deficient practice. The maintenance department split up to inspect all doors in the building. No outstanding issues were noted. III. Systemic Changes The Maintenance department was in-serviced about Smoke Barrier Construction. Maintenance will inspect all areas of service after any construction is completed. IV. QA Monitoring All smoke barriers will be inspected monthly for one quarter. The Director of Maintenance will review all logs on a quarterly basis. This report will be done by the Director of Maintenance or his designee and submitted to the QA committee for review. QAPI committee to determine if further action is required. Responsible Party: Director of Maintenance
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brooklyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Phoenix Rehabilitation And Nursing Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Concord Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 18 | 0 |
| New Carlton Rehab And Nursing Center, Llc | 1.2 mi | ★★★★★ | 0 | 0 |
| Buena Vida Rehab And Nursing Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Oxford Nursing Home | 1.6 mi | ★★★★★ | 4 | 0 |
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