Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Brooklyn Gardens Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions had physician-ordered wound care for a right medial bunion, but the treatment administration record and nursing progress notes showed numerous dates where wound care was not documented as completed. Interviews with LPNs and facility leadership revealed uncertainty about whether the care was provided, and no documentation was found to explain the omissions, contrary to facility policy requiring complete and accurate medical records.
A resident with end stage renal disease and pressure ulcers experienced a significant weight loss of over 5% in one month. Despite facility policy requiring notification, the resident's representative was not informed of this change, and no documentation of notification was found in the medical record. Staff interviews revealed confusion over who was responsible for notifying the representative.
Two residents with behavioral and cognitive challenges were involved in an altercation after one wandered into the other's room through a shared bathroom. Despite care plans and staff monitoring, the wandering resident was able to enter the room unsupervised and was physically assaulted, sustaining a lip injury. Staff interviews confirmed that both residents required close observation and redirection, but the incident occurred when staff were not present to intervene.
The facility did not submit the results of an abuse investigation to the state health department within the required five-day period after an incident where a resident struck two others, causing injuries. The DON and Administrator were aware of the reporting requirements but acknowledged the report was submitted late, with no explanation provided for the delay.
Surveyors identified that two residents received IV therapy that did not meet professional standards: one received expired IV fluids, and another had an undated IV site dressing and incomplete physician orders lacking infusion rate and site care instructions. Nursing staff failed to check expiration dates, properly document, and ensure complete orders, while oversight by the DON and medical providers was insufficient.
Dietary staff were observed handling food and utensils without properly covering facial hair, contrary to facility policy requiring beard guards for infection control. Staff interviews confirmed lapses in following the required uniform standards, and facility leadership acknowledged the expectation for all facial hair to be covered during food preparation.
An LPN failed to follow infection control protocols while administering medications to a resident with a gastrostomy tube, including not performing hand hygiene, not changing gloves after picking up a dropped medication, and not donning required PPE despite posted Enhanced Barrier Precautions. The LPN, who was newly hired and had received relevant training, did not notice the signage or available PPE supplies.
The facility did not post required notices about the availability of survey results in prominent and accessible areas, as confirmed by observations, staff interviews, and resident feedback. Residents were unaware of where to find survey results, and staff had not discussed or observed any postings regarding their availability.
A resident with moderate cognitive impairment and using a rollator walker eloped from the facility without being stopped by security guards. The resident was not identified as an elopement risk, and an elopement care plan was not in place. Surveillance footage showed the resident exiting past two security guards who failed to follow the facility's policy of checking identification and ensuring residents do not leave unescorted.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards and practices for one resident. Specifically, a resident with diagnoses including non-Alzheimer's dementia, congestive heart failure, and peripheral arterial disease had a physician's order for daily wound care to the right medial bunion. The treatment administration record and nursing progress notes showed multiple dates over a two-month period where wound care was not documented as completed, and there was no documentation explaining the omissions. The facility's policy required that all events pertaining to a resident's stay, including treatments, be documented by licensed professionals. Interviews with nursing staff and facility leadership revealed uncertainty about whether the wound care was provided on the undocumented dates. Staff members could not recall the resident or the specific treatments, and some suggested that either the wound care team performed the treatment or the resident was not present or refused care. However, there was no documentation to support these explanations. The Assistant Director of Nursing confirmed that no additional documentation could be found to clarify the missing entries, and stated that unsigned treatment administration records indicate that care was not rendered.
Failure to Notify Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the designated representative of a resident's significant weight loss, as required by its own policy and regulatory standards. The resident in question had multiple diagnoses, including end stage renal disease and stage 2 and 3 pressure ulcers. The resident experienced a weight loss of more than 5% in one month, as documented in both the weight monitoring records and dietary notes. Despite this significant change, there was no documented evidence in the medical record that the resident's representative was informed of the weight loss. Interviews with facility staff, including a registered nurse, social worker, and dietitian, revealed that each believed the responsibility for notifying the representative lay with another staff member. The dietitian confirmed that the weight loss was significant and that notification should have occurred, but upon review of the dietary notes, found no documentation of such notification. The administrator also acknowledged that notification and documentation were required in cases of significant weight change, but confirmed that this did not occur for the resident.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by an incident involving two residents with cognitive and behavioral challenges. One resident, who had severe cognitive impairment and a history of wandering and aggressive behaviors, entered another resident's room through a shared bathroom. The second resident, who had intact cognition but was known to be verbally aggressive and did not want others entering their room, responded by physically assaulting the wandering resident, resulting in an abrasion and swelling to the upper lip. Documentation showed that the care plan for the wandering resident included interventions such as staff observation during rounds, monitoring for mood changes, and keeping the resident away from peers whenever possible. Nursing instructions also noted the resident's behaviors of wandering, aggression, and resistance to care. Despite these interventions, the resident was able to access another resident's room unsupervised, leading to the altercation. Staff reported performing hourly rounding and monitoring, and both residents were known to require redirection and close observation due to their behaviors. Interviews with staff confirmed that the wandering resident was last seen in their own room shortly before the incident and that staff typically redirected them when observed wandering. The resident who committed the assault had previously expressed a desire for privacy and resistance to others entering their room. The incident occurred when staff were not present to intervene, and the facility's investigation concluded that there was no credible evidence of neglect, abuse, or mistreatment, despite the physical injury sustained.
Late Submission of Abuse Investigation Findings to State Authorities
Penalty
Summary
The facility failed to ensure that the results of all investigations into alleged abuse, neglect, exploitation, or mistreatment were reported to the administrator or their designee and to the appropriate state authorities within five working days, as required by both facility policy and state regulations. Specifically, an incident occurred in which one resident struck two other residents with a wheelchair footrest, resulting in injuries: one resident sustained an injury above the right eyebrow, and another developed a large swelling on the right arm. The facility conducted an investigation and determined that the incident did not meet the definition of abuse due to the absence of a prior pattern of aggression or clear intent to harm. However, the results of this investigation were not submitted to the New York State Department of Health within the mandated five-day period; instead, the findings were submitted three days late. The residents involved had varying medical histories, including end stage renal disease, diabetes mellitus, depression, hypertension, and cerebrovascular disease, with cognitive assessments ranging from moderately impaired to intact. Interviews with the DON and Administrator confirmed that both were aware of the reporting requirements and acknowledged the late submission of the five-day report. The Administrator could not provide a reason for the delay in submitting the investigation results to the state agency.
Deficient IV Fluid Administration and Documentation
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids in accordance with professional standards of practice for two out of three residents reviewed for hydration. In one instance, a resident with severe cognitive impairment and a dislodged gastrostomy tube was observed receiving IV fluids from a bag that was past its expiration date. The LPN who administered the IV fluids admitted to not checking the expiration date before use, and the Unit Manager was unaware that expired fluids were being administered. The DON confirmed that nurses are required to verify both the match to the physician's order and the expiration date of IV solutions before administration. In another case, a resident with intact cognition and a need for IV hydration due to diarrhea was found with an undated peripheral IV catheter dressing. The physician's order for IV hydration lacked critical details, including the infusion rate and instructions for assessment and maintenance of the IV site. There was also no documented order for the insertion of the IV line or for dressing changes. The Medication Administration Record did not specify the infusion rate, and the Treatment Administration Record lacked documentation of site inspection, assessment, or dressing changes as required by facility policy. Interviews with nursing staff and the DON revealed lapses in following established protocols, such as failing to date IV dressings and not ensuring complete and accurate physician orders for IV therapy. The attending physician and medical director both acknowledged that the orders were incomplete and not properly reviewed or signed. These deficiencies were observed during the recertification survey and were not accompanied by any corrective or follow-up actions in the report.
Failure to Ensure Proper Facial Hair Restraint During Food Handling
Penalty
Summary
During a recertification survey, it was observed that dietary staff did not consistently follow professional standards for food service safety and infection control in the kitchen. Specifically, one dietary aide was seen handling utensils and scooping watermelon while having a visible mustache and goatee without a beard cover. Another dietary aide was observed on the tray line handling various food items with their beard guard positioned below their mustache, leaving facial hair uncovered. These actions were in direct violation of the facility's policy, which requires all facial hair to be covered by a beard guard when handling food. Interviews with the involved staff revealed that one aide forgot to wear the beard cover, while the other stated they were previously instructed to only cover the bottom part of their face. Both the Food Service Supervisor and Food Service Director confirmed that the facility's uniform policy mandates the use of hair restraints and beard guards for staff with facial hair to prevent hair from contaminating food. The failure to adhere to these standards resulted in a deficiency related to food safety and infection control practices.
Failure to Follow Infection Control Protocols During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to adhere to infection control protocols during medication administration to a resident with a gastrostomy tube. The LPN did not perform hand hygiene before donning gloves to prepare medications, picked up a medication that had fallen on the floor with the same gloved hands, and continued to administer medications without changing gloves or performing hand hygiene. Additionally, the LPN did not don the required personal protective equipment (PPE) before entering the resident's room, despite signage indicating the need for Enhanced Barrier Precautions. Interviews revealed that the LPN was newly hired and had received orientation and in-service education on infection prevention, including hand hygiene and Enhanced Barrier Precautions. The LPN stated they did not notice the signage or the availability of PPE supplies near the resident's room. Facility leadership confirmed that infection control education and signage were in place and that supplies were accessible, but the LPN did not follow established protocols during the observed medication administration.
Failure to Post Survey Results Notice in Prominent Areas
Penalty
Summary
The facility failed to ensure that notices regarding the availability of survey results were posted in prominent and accessible areas, as required by both facility policy and regulatory standards. Multiple observations throughout the facility, including the main lobby, revealed that there were no posted notices indicating where survey results could be reviewed. The facility's policy specifies that such notices must be visibly posted in designated areas, but this was not adhered to during the survey period. During a Resident Council meeting, all residents in attendance reported that they did not know where to find the survey results and had not seen any notices about their availability. Additionally, review of previous Resident Council meeting minutes showed no documentation that residents were informed about the location of survey results. Interviews with staff, including the Recreation Director, confirmed that the topic had not been discussed and that no signage was observed. The Administrator acknowledged that the signage had previously been present but was not currently posted.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident, which was evident in one out of sixteen residents sampled for elopement. The incident occurred when a resident with a history of Schizophrenia Disorder and Cerebral Infarction, who was not identified as at risk for elopement, exited the facility unescorted. The resident, who had moderate cognitive impairment and used a rollator walker, was last seen on the unit at 11:00 AM. Surveillance footage showed the resident walking past two security guards without being stopped, exiting through the automatic front doors and the front gate leading to the street. The facility's policies on elopement prevention and security reception were not effectively implemented. Security Guard #1, stationed at the front desk, was observed talking to another resident and did not stop the resident from leaving. Security Guard #2, stationed at the front gate, was not paying attention and did not notice the resident leaving. The resident was not identified as an elopement risk upon admission, and an elopement care plan was not in place. The facility staff became aware of the resident's absence between 12:30 PM and 1:00 PM, and a search was initiated, but the resident was not found until later. Interviews with facility staff revealed that the security guards did not follow the facility's policy of checking identification and ensuring residents do not leave the facility unescorted. The resident was wearing an identification band, but the security guards failed to verify it. The facility's Director of Nursing and Administrator were informed of the incident, and local law enforcement was contacted. The resident was eventually found at a hospital and returned to the facility without injury.
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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) |
|---|---|---|---|---|
| Brooklyn Center For Rehabilitation And Residential | 0.4 mi | ★★★★★ | 9 | 0 |
| Crown Heights Center For Nursing And Rehabilitatio | 0.7 mi | ★★★★★ | 5 | 0 |
| Concord Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 18 | 0 |
| Buena Vida Rehab And Nursing Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Rutland Nursing Home, Inc | 1.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.