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 Brooklyn-queens Nursing Home during CMS and state inspections, most recent first.
A facility failed to update comprehensive care plans for three residents, leading to care plans that did not reflect current preferences and medical needs. One resident's preference for hospital gowns and refusal of hair care were not documented, another resident's victimization care plan was not revised after an injury, and a third resident's pain and anticoagulant care plans were outdated. Staff interviews revealed a lack of documentation and oversight in care plan management.
A resident with severe cognitive impairment was found with a bruise of unknown origin, which was not reported to the state agency within the required 2-hour timeframe. Despite immediate internal reporting, the facility delayed external reporting due to system access issues, resulting in a deficiency citation.
A cognitively intact resident was not invited to participate in their initial care plan meeting, contrary to facility policy. Interviews with staff confirmed the oversight, and no documentation was found to show that the resident or their representative was invited, despite the resident's ability to make decisions.
The facility failed to accurately code the MDS 3.0 assessments to reflect resident participation in assessments and goal setting. Three residents with various diagnoses were involved, and interviews confirmed their involvement in care planning. The error was attributed to a miscommunication within the social services department, as the Assistant Director responsible for coding had left the facility. The Director of Social Services admitted the mistake, and the Administrator was unaware of the issue.
Expired food items were found in various storage areas of the facility, including the kitchen and pantry, due to inadequate adherence to storage protocols and lack of oversight. Staff interviews revealed confusion over responsibilities for checking and rotating stock, contributing to the deficiency.
A resident with dementia and other health issues sustained an elbow excoriation due to friction. The facility's policy requires notifying the resident's representative of such changes, but this was not done. The medical team was informed, but there was no documentation of communication with the representative.
A resident with severe cognitive impairment was found on the floor, and the facility's investigation concluded it was an accidental fall. However, the investigation findings were not reported to the New York State Department of Health within the required 5 working days, as per facility policy. The delay was attributed to a misunderstanding by the DON and an oversight by the Administrator.
A resident with dementia, hypertension, and diabetes developed an excoriation on their elbow due to friction from bed sheets. Despite this, the facility failed to create a care plan to address the skin impairment, as required by their policy. The wound care nurse confirmed the need for a care plan, but it was not initiated.
A facility failed to update a resident's care plan after an incident where another resident approached them with a knife. The resident, who has moderately impaired cognition and a history of dementia, was not provided with an updated care plan despite the facility's policy requiring revisions based on changes in status. The incident was investigated, and it was concluded that abuse did not occur, but the care plan remained unchanged.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised to reflect the current status and preferences of residents. This deficiency was observed in the cases of three residents during a recertification and complaint survey. One resident, diagnosed with depression, paranoid schizophrenia, and insomnia, had a care plan that did not reflect their preference for wearing hospital-style gowns and refusal to have their hair care needs addressed. Despite multiple observations of the resident with matted hair and wearing a hospital gown, there was no documentation or revision of the care plan to address these preferences and needs. Another resident, with diagnoses including vascular dementia and cerebral atherosclerosis, was found with a bruise of unknown origin. The care plan related to victimization was not reviewed or revised following the incident or after the completion of the Minimum Data Set assessments. This lack of documentation and revision left the resident's care plan outdated and not reflective of their current condition and needs. A third resident, with diagnoses of unspecified atrial fibrillation and chronic pain syndrome, was receiving anticoagulant and opioid medications. However, their care plans related to pain management and anticoagulant use were not reviewed or updated after the last Minimum Data Set assessment. The facility's failure to update these care plans as required by their policy resulted in care plans that did not accurately reflect the residents' current medical needs and interventions.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an incident involving a resident with injuries of unknown origin to the New York State Department of Health within the required 2-hour timeframe. The incident involved a resident with severe cognitive impairment due to conditions such as Vascular Dementia and Cerebral Infarction. On July 12, 2024, a Certified Nursing Assistant observed a bruise on the resident's left upper arm, which was blueish in color and measured 10cm x 5cm. The incident was documented in the nursing notes, and the medical assessment confirmed the presence of a bruise with a mild hematoma. Despite the immediate reporting of the incident to the Director of Nursing by the Registered Nurse, the facility did not report the incident to the state agency until July 13, 2024, exceeding the mandated reporting window. The facility's policy requires that all alleged violations, including injuries of unknown source, be reported immediately, but not later than 2 hours after the allegation is made. The Administrator confirmed that the Director of Nursing and themselves were responsible for reporting such incidents to the Department of Health. However, due to issues with system access, the report was delayed. The Director of Nursing, who was responsible for the initial reporting, was no longer employed at the facility at the time of the survey, and the Administrator could not provide an explanation for the delay in reporting. This failure to adhere to the reporting policy resulted in a deficiency citation during the survey.
Failure to Involve Resident in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident or their representative participated in the development, review, and revision of the comprehensive care plan, as required. Specifically, a resident who was cognitively intact and capable of making decisions was not invited to the initial care plan meeting. The facility's policy mandates that residents or their representatives be invited to these meetings, and any inability to participate should be documented in the medical record. However, there was no evidence in the medical record that the resident or their representative was invited to or participated in the care plan meeting. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Social Services, confirmed that the resident was alert, oriented, and capable of making decisions. The Director of Social Services acknowledged that it was their responsibility to invite the resident to the care plan meeting and admitted that there was no documented evidence of such an invitation. The oversight was attributed to a failure to document the invitation in the medical record, as required by the facility's policy.
Inaccurate MDS Coding for Resident Participation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) 3.0 assessments were accurately coded to reflect the participation of residents and/or their representatives in the assessment and goal setting process. This deficiency was identified during a recertification survey conducted from September 3, 2024, to September 10, 2024, and involved three residents out of a sample of 31. Specifically, the MDS assessments for these residents did not accurately document their participation, despite interviews indicating that they were involved in care planning meetings and assessments. The residents involved had various diagnoses, including hypertension, peripheral vascular disease, chronic respiratory failure, congestive heart failure, major depressive disorder, unspecified pain, multidrug-resistant organism, and end-stage renal disease. The issue stemmed from a miscommunication and lack of oversight within the facility's social services department. The Director of Social Services acknowledged that the responsibility for coding the participation question in the MDS assessments fell to the Assistant Director of Social Services, who had left the facility weeks prior. The Director admitted that it was an error to code the assessments as if the residents had not participated and noted that training had been provided to the Assistant Director, with subsequent reviews of completed assessments showing no concerns until the error was discovered. The facility's Administrator was unaware of the incorrect coding and suggested it might have been due to a misunderstanding of the question.
Expired Food Items Found in Storage Areas
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety, as observed during a recertification survey. Multiple expired food items were found in the kitchen dry storage room, emergency food room, and the pantry on the 5th floor. The facility's policy required that food be stored using a first-in, first-out system, but this was not adhered to, leading to the presence of expired items such as Jevity, Ready Care Clear Choice Thickened Water, Boost Pudding, Two Cal HN, and Nepro Carb Steady. Interviews with staff revealed a lack of consistent oversight and responsibility for checking and rotating stock. Dietary Aide #1 admitted to noticing expired items but did not have time to remove them, and there was no supervisor on weekends. The Food Service Supervisor, who was supposed to inspect storage areas regularly, did not notice the expired items. Additionally, there was confusion among staff about who was responsible for checking the pantry for expired items, with some staff believing it was not their duty. The Director of Nursing and other nursing staff were unaware of the expired supplements in the pantry, and there was a lack of communication between dietary and nursing staff regarding the storage and distribution of supplements. The Director of Nursing stated that enteral feeding should not be stored prior to use, yet expired supplements were found in the pantry. This indicates a breakdown in protocol adherence and supervision, contributing to the deficiency.
Failure to Notify Resident's Representative of Condition Change
Penalty
Summary
The facility failed to notify a resident's designated representative of a change in the resident's condition, which is a requirement according to their policy. This deficiency was identified during an abbreviated survey, where it was found that a resident sustained an excoriation to the right elbow due to friction. Although the medical doctor and wound care nurse were informed, there was no documented evidence that the resident's representative was notified of this change in condition. The resident involved had a history of Non-Alzheimer's Dementia, Hypertension, and Diabetes Mellitus, with moderately impaired cognition. The wound care nurse and the Director of Nursing confirmed during interviews that there was no communication with the resident's representative regarding the skin impairment. The facility's policy mandates prompt notification of the resident, attending physician, and resident representative in such cases, but this was not adhered to in this instance.
Delayed Reporting of Investigation Findings
Penalty
Summary
The facility failed to report the results of an investigation into an incident involving a resident to the appropriate authorities within the required timeframe. The incident occurred when a resident with a history of traumatic brain injury, hemiplegia, and seizure disorder was found on the floor mat in their room. The resident was alert but confused, and the fall was determined to be an accident. The investigation was completed on October 17, 2023, but the findings were not submitted to the New York State Department of Health until the same day, which exceeded the 5 working days reporting requirement. The facility's policy mandates that investigation results be reported to the administrator and relevant officials, including the State Survey Agency, within 5 working days of the incident. However, the Director of Nursing and the Administrator acknowledged that the report was not submitted on time due to a misunderstanding and oversight. The Director of Nursing believed further action was unnecessary, while the Administrator was unaware of the delay until it was brought to their attention.
Failure to Implement Comprehensive Care Plan for Skin Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and time frames for a resident, leading to a deficiency. Specifically, a resident was observed with an excoriation on their right elbow due to friction from rubbing against bed sheets. Despite the presence of this skin impairment, no care plan was developed to address or prevent the friction, which is a requirement according to the facility's policy and procedure for comprehensive care planning. The resident involved had a medical history that included Non-Alzheimer's Dementia, Hypertension, and Diabetes Mellitus, and was noted to have moderately impaired cognition. The wound care nurse confirmed that the excoriation was due to the resident's uncontrollable movements and that a care plan should have been initiated but was not. The deficiency was identified during an abbreviated survey, and attempts to contact the responsible registered nurse supervisor were unsuccessful as they were no longer employed at the facility.
Failure to Update Care Plan After Incident Involving Knife
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team following an incident involving another resident. Specifically, the incident occurred when a visitor reported that a resident approached another resident with a knife. The knife was brought into the facility by the family of the resident who possessed it. Although the facility investigated the incident and concluded that abuse did not occur, the care plan for the resident who was approached with the knife was not updated to reflect this incident. The resident involved in the incident had a history of Non-Alzheimer's Dementia, Hypertension, and Diabetes Mellitus, with a documented moderately impaired cognition. The existing care plan for this resident included interventions for providing emotional support and reassurance. However, despite the incident, the care plan was not revised to address the new circumstances. The facility's policy requires that care plans be revised as needed based on changes in the resident's condition or status, which was not adhered to in this case.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 United Methodist Church Home | 0.1 mi | ★★★★★ | 0 | 0 |
| Linden Center For Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| Bushwick Center For Rehabilitation And Health Care | 1.9 mi | ★★★★★ | 0 | 0 |
| Spring Creek Rehabilitation & Nursing Care Center | 2 mi | ★★★★★ | 1 | 0 |
| Atrium Center For Rehabilitation And Nursing | 2.4 mi | ★★★★★ | 0 | 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.