Below 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 United Methodist Church Home during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment experienced left eye pain and swelling, leading to a new physician order for eye drops. Although the resident was alert and the plan of care was discussed with them, there was no documentation that the representative was notified of this change in condition, as required by facility policy. Staff interviews confirmed the notification protocol was not followed.
A CNA struck a cognitively impaired resident on the shoulder after the resident threw liquid at them, as confirmed by surveillance footage and a witness. The incident was not reported immediately to supervisory staff, and the resident was later assessed with no injuries or pain. The facility determined that staff-to-resident abuse had occurred, in violation of policy.
A resident with severe cognitive impairment and multiple diagnoses was struck on the shoulder by a CNA after tossing liquid, as observed on surveillance video and witnessed by a housekeeper. Although the incident was reported internally and investigated, the facility did not notify law enforcement within the required two-hour window, instead reporting the abuse after more than three hours, contrary to policy and regulations.
During a survey, it was found that the handrails in the East and West stairwells of the facility lacked the required contrasting colored marking stripe, violating NFPA 101 standards. The Director of Environmental Services acknowledged the issue and stated that corrective action would be taken.
The facility failed to provide timely Medicare non-coverage notices to residents or their representatives, using incorrect forms and not adhering to the required two-day advance notice. This deficiency affected three residents, with notices being signed on the same day as discharge from skilled services.
The facility failed to maintain a safe and sanitary environment, with issues such as disrepair and dirt in Unit 3, stained and cracked ceiling tiles, and unclean wheelchairs. Staff interviews revealed challenges in maintaining cleanliness, with the Director of Environmental Services noting difficulties in washing wheelchairs and a leaking roof causing stained tiles. The Administrator acknowledged the importance of cleanliness for infection control and staff morale.
The facility failed to maintain a safe and clean environment on Unit 3, with a wobbly toilet seat in the staff bathroom and significant dust and dirt accumulation in the Nurse's Station. Interviews revealed unclear cleaning responsibilities between housekeeping staff and nurses, contributing to the unsanitary conditions.
A life safety survey found that a deep fryer in the facility's first-floor kitchen was installed too close to a cooking surface, violating NFPA 96 standards. The fryer lacked the required 16-inch space or an 8-inch baffle plate between it and adjacent cooking equipment with surface flames.
The facility was cited for not maintaining a policy for the use of extension cords and power strips. During a survey, power strips were found in use on the first and second floors without visible UL listings, indicating non-compliance with safety standards. Additionally, no policy was available for review, highlighting a failure to adhere to necessary safety regulations.
A life safety survey revealed that the facility did not have self-closing or automatic closing doors for hazardous areas on the first floor. This included a dining room used for furniture storage and a laundry room in the exit passageway. The Director of Environmental Services confirmed the need for self-closers.
A resident with severe cognitive impairments and stage 4 pressure ulcers received wound care from an LPN who failed to maintain proper infection control practices. The LPN placed a sterile drape on a soiled table, used unwrapped scissors, and did not perform hand hygiene between glove changes. The facility's Infection Preventionist oversees wound care but lacks routine documentation of observations.
The facility was found non-compliant with NFPA 101: 19.1.6.1 due to its four-story Type II (000) construction, which exceeds the allowed two stories and requires complete sprinkler protection. Observations revealed unprotected steel beams and ceilings on floors two through four. The Administrator noted a time-limited waiver and funding delays due to the facility's non-profit status, with some progress made in replacing fixtures and ceiling tiles.
The facility failed to conduct the required three-year, four-hour load test on its emergency generators, as per NFPA standards. This deficiency was identified during a document review, and the Administrator acknowledged the oversight, stating that a vendor would be contracted to perform the test.
The facility failed to make survey results from the past three years readily available to residents and visitors, with only 2023 results present in the survey binder. Notices about the availability of these results were not posted in prominent areas, and residents were unaware of where to find them. The Director of Activities and the Administrator acknowledged the lack of postings and awareness of the requirement to provide access to these documents.
The facility did not post actual nursing staffing numbers and hours in a location accessible to residents and visitors. Staffing postings were based on projections and placed in an inaccessible area. Interviews revealed a lack of awareness among staff about the requirement to post actual staffing information visibly.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a resident's designated representative of a change in the resident's condition. The incident involved a resident with a history of hypertension and cerebrovascular accident, who was documented as having moderate cognitive impairment. On 11/05/2024, the resident complained of left eye pain, and an assessment revealed mild swelling. The medical doctor was informed, and an order for Diclofenac eye drops was issued. Documentation showed that the resident was alert and oriented and that the physician discussed the plan of care directly with the resident. However, there was no documented evidence that the resident's representative was notified of the change in condition, as required by facility policy. The issue was further substantiated when the resident's representative visited and observed the eye swelling, stating they had not been informed of the condition. Interviews with facility staff, including the social worker, RN supervisor, DON, and administrator, confirmed that the protocol is to notify the family or representative of any change in condition. Staff acknowledged that the representative should have been notified, but there was no record of such communication. The facility's policy, revised in 01/2025, also requires notification of the resident's representative in the event of a change in condition.
Staff-to-Resident Physical Abuse Following Resident Aggression
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically struck a resident on the left upper shoulder with the back of their hand in the facility's dining room. The incident was captured on surveillance video and witnessed by a housekeeper. The event was triggered after the resident, who has severe cognitive impairment and a history of schizophrenia, threw liquid at the CNA. The CNA responded by hitting the resident and then leaving the dining room. The housekeeper, who observed the incident, subsequently escorted the resident out of the dining room and reported the event to nursing staff. The resident involved was identified as being at risk for victimization due to observed verbal aggression and socially inappropriate behavior, as documented in their care plan. At the time of the incident, the resident was assessed and found to have no visible injuries, pain, or discomfort. The CNA denied hitting the resident, claiming instead to have rubbed the resident's back, but both the surveillance footage and the housekeeper's account confirmed the physical contact. The housekeeper also reported hearing a popping sound and stated that the resident told them they had been punched. There were delays in reporting the incident to supervisory staff. The housekeeper reported the event to an LPN, who did not immediately inform the registered nurse supervisor, citing that they were in the process of distributing medication. The registered nurse supervisor was eventually informed and reviewed the surveillance footage before proceeding to the unit. The administrator and director of nursing were notified later, and the incident was discussed among the administrative team. The facility's policy prohibits any form of abuse, and the event was determined to be a violation of this policy.
Failure to Timely Report Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to law enforcement within the required two-hour timeframe. Surveillance video showed that a certified nursing assistant (CNA) struck a resident on the shoulder after the resident, who has severe cognitive impairment and diagnoses including hypertension and schizophrenia, tossed liquid behind them, wetting the CNA. A housekeeper present in the dining room witnessed the incident and reported it to the registered nurse supervisor approximately 30 minutes later. The facility's investigation confirmed that abuse had occurred, and the CNA was suspended and later terminated. Despite facility policy and state regulations requiring immediate reporting of abuse allegations to law enforcement within two hours, the facility did not notify law enforcement until over three hours after the incident. The delay was attributed to the facility gathering information before making the report. Both the Director of Nursing and the Administrator acknowledged that the notification to law enforcement was not made within the required timeframe.
Non-compliance with NFPA 101: Missing Handrail Markings
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101 Life Safety Code during a life safety survey conducted on January 6, 2025. The surveyors observed that the handrails in both the East and West stairwells lacked the required contrasting colored marking stripe along the entire length of the stairwells. This deficiency was noted during the survey conducted between 9:00 am and 12:00 pm. The Director of Environmental Services acknowledged the absence of the required markings on the handrails and stated that the rails would be painted immediately. The lack of these markings is a violation of the NFPA 101 standards, which require that all handrails and handrail extensions in egress stairs be marked with a solid and continuous marking stripe to ensure safety and compliance.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 I. Immediate Corrective Action The maintenance staff has permanently marked the handrails with the required contrasting yellow colored marking stripe for the length of the handrails in the East and West stairwells. II. Identification of Other Residents The facility acknowledges that the residents have the potential to be affected by this practice. The facility respectfully states that once the handrails on both the East and West stairwells from the first (1st) to the fourth (4th) floors were permanently marked with contrasting yellow marks, no other residents were affected by this practice. III. Systemic Changes The Director of Environmental Services will in-service the maintenance staff related to this requirement; lesson plan and attendance shall be filed for validation. The Director of Environmental Service/designee will inspect the stairs monthly for proper markings. The Director of Environmental Service will develop an audit tool to track compliance. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that the exit stair landings are marked with a solid continuous marking stripe. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible party: Director of Environmental Service
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide appropriate notification to residents or their designated representatives at the termination of Medicare Part A benefits, as required by regulations. This deficiency was identified during a recertification survey for three residents. The facility did not provide the required Notice of Medicare Non-coverage Form (CMS Form 10123) at least two calendar days before the end of Medicare-covered services. Instead, the notices were signed on the same day as the discharge from skilled services. Additionally, the incorrect form, CMS-R-131, was used instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055. The Director of Social Services indicated that the notices were given as soon as they received information from the Rehabilitation department, but they were unsure of the correct timeframe for providing these notices. The Administrator was not aware of the untimely notifications and the use of incorrect forms. The deficiency was evident for three residents, with one resident's spouse being notified a day before the discharge but still signing the form on the discharge day. The facility's policy was not aligned with the regulatory requirement of providing notices two days in advance, leading to the deficiency.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as observed during a recertification survey. On Unit 3, multiple deficiencies were noted, including ceiling tiles that were in disrepair, cracked, stained, and not firmly affixed. Corridor borders were layered with dirt and dust, and specific rooms had additional issues such as water-stained ceiling tiles, broken wall bumpers, and chipped sinks. Wheelchairs in several rooms were found to be heavily stained with dried food particles and dirt, and the dining room contained a dusty piano, stained walls, and dusty window blinds. Interviews with staff revealed challenges in maintaining cleanliness. Housekeeper #2 described their cleaning routine but acknowledged that heavy-duty cleaning is also necessary. The Director of Environmental Services admitted difficulties in washing wheelchairs and noted ongoing issues with a leaking roof, which contributed to the stained ceiling tiles. The Administrator recognized the importance of cleanliness for infection control and staff morale and mentioned plans for facility improvements, including replacing furniture and repairing the roof, although these actions were not yet completed.
Environmental Safety and Cleanliness Deficiency
Penalty
Summary
The facility failed to ensure a safe and functional environment for residents, staff, and the public, as observed during a recertification survey. On Unit 3, the staff bathroom adjacent to the Tub Room had a loose and wobbly toilet seat, which could pose a safety risk. Additionally, the Nurse's Station was found to be inadequately cleaned, with dust and dirt accumulating on various surfaces, including the Plexiglass, swivel chairs, call bell console, floors underneath the desk, and computer screen monitors and phones. Interviews with the housekeeping staff and the Director of Environmental Services revealed a lack of clarity and execution in cleaning responsibilities. Housekeeper #2 indicated that only the floors in the Nurse's Station were cleaned, and they assumed that nurses were responsible for wiping down their own equipment. The Director of Environmental Services stated that housekeeping staff should clean the Nurse's Station and could coordinate with the unit nurse about cleaning areas, but also mentioned that nurses were expected to maintain their stations free from dust. This lack of clear cleaning protocols contributed to the unsanitary conditions observed.
Non-compliance with NFPA 96 Standards in Kitchen Equipment Installation
Penalty
Summary
During a life safety survey conducted on January 6, 2025, it was observed that the facility's kitchen on the first floor had a deep fryer positioned within 16 inches of a cooking surface, which is not in compliance with NFPA 96 standards. The standard requires a minimum of 16 inches of space between a deep-fat fryer and adjacent cooking equipment with surface flames, unless a steel or tempered glass baffle plate of at least 8 inches in height is installed between them. In this case, there was no physical barrier present between the fryer and the hot surface. This deficiency was confirmed through observation and a staff interview with the Facilities Director, who acknowledged the issue and mentioned plans to install a metal baffle.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 I. Immediate Corrective Action The maintenance staff permanently installed an 8” tall steel plate onto the deep-fat fryer separating it from the adjacent cooking equipment. II. Identification of Other Residents Once the 8” tall steel plate was installed onto the deep-fat fryer, the only deep-fat fryer in the facility was permanently separated from the adjacent cooking equipment. The facility respectfully states that no other residents were affected by this practice. III. Systemic Changes The Environmental Service Director will provide in-service education to all maintenance staff and the Director of Food Service related to the requirements of 2010 NFPA 9612.1.2.5, specifically the significance of the separation of deep-fat fryers adjacent to other cooking equipment. Lesson plan and attendance will be filed for validation. The Environmental Service Director will develop an audit tool to track compliance with this requirement. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor for the proper separation of the deep-fat fryer and the adjacent cooking equipment. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service
Deficiency in Power Strip Policy and Compliance
Penalty
Summary
The facility was found to be deficient in maintaining a policy for the use of extension cords and power strips during a life safety survey. On the first and second floors of the building, power strips were observed in use without visible UL listings, which are necessary to ensure compliance with safety standards. Specifically, a power strip was noted at the second-floor nurses' station, and in the first-floor conference room, two large wall-mounted monitors/screens were plugged into power strips without visible UL listings. During the document review, it was discovered that the facility did not have a policy available for the use of power strips. This lack of documentation and policy indicates a failure to adhere to the necessary safety regulations as outlined by the NFPA and other relevant codes. The absence of a policy and the use of potentially non-compliant power strips could pose a risk to the safety of the facility's environment.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 I. Immediate Corrective Action The maintenance department purchased and installed power strips having a visible ULL listing of UL1363A at the second (2nd) floor nurse station and the conference room. The Administrator developed the policy and procedure for power strips utilized in the facility. II. Identification of other Residents The Environmental Service Director toured the entire facility and no other power strips were identified that did not have a visible or proper ULL listing of UL 1363A. The facility respectfully states that once the maintenance department installed the power strips with a visible and proper ULL listing of UL1363A, no other residents were affected by this practice. III. Systemic Changes The Environmental Service Director reviewed and revised the Electrical Safety policy and procedure. All maintenance staff will receive in-service education and understand the life safety issues and the importance of ensuring compliance with the Electrical Safety Policy and Procedures with an emphasis on power strips and extension cord prohibitions. Lesson plan and attendance will be filed for validation. The Environmental Service Director will develop an audit tool to track compliance with this requirement. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that any and all power strips utilized in the facility will have a visible ULL listing and that the listing be UL 1363A. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service
Deficiency in Self-Closing Doors for Hazardous Areas
Penalty
Summary
During a life safety survey conducted on January 6, 2025, it was observed that the facility failed to ensure that all doors protecting hazardous areas were equipped with self-closing or automatic closing mechanisms. This deficiency was noted on the first floor of the building, specifically involving the door to a large dining room being used to store a shipment of furniture and the laundry room door in the exit passageway leading to the loading dock. The absence of self-closing doors in these areas was confirmed through observation and staff interviews, with the Director of Environmental Services acknowledging the need for installation of self-closers.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 I. Immediate Corrective Action The maintenance department installed self-closing hinges to the dining area doors located on the first (1st) floor, compliant with 19.3.2.1.3 N.B. – The dining room housed a delivery of furniture that has been returned to the company. The maintenance department also installed self-closing hinges to the laundry room door, compliant with 19.3.2.1.3. II. Identification of Other Residents The Environmental Service Director inspected all doors to hazardous areas in the facility and found same to be compliant. Once the dining room doors and the laundry room door had self-closing hinges installed, the facility respectfully states that no other residents were affected by this practice. III. Systemic Changes The Environmental Service Director will provide In-service education to all maintenance staff related to the requirements of Hazardous area protection. Lesson Plan and Attendance will be filed for validation. The Environmental Service Director will develop an audit tool to track compliance. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that all hazardous area doors are compliant with 19.3.5.9. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for a resident with pressure ulcers. The resident, who had severe cognitive impairments and was dependent on assistance for transfers, had two stage 4 pressure ulcers. During a wound care observation, an LPN placed a sterile drape on a visibly soiled overbed table without cleaning it first. The LPN used an unwrapped scissor to open wound care supplies and did not perform hand hygiene between glove changes during the procedure. The LPN admitted to not being as organized as usual and acknowledged not following proper hand hygiene protocols during the wound care process. The LPN also assumed that the overbed table had been cleaned by a home health aide, which was not the case. The LPN expressed that they had received training on wound care but suggested that refresher training would be beneficial. Interviews with the facility's nursing staff revealed that the Infection Preventionist, who is also the Assistant Director of Nursing, is responsible for wound care assessments and competencies. However, routine observations of wound care practices were not documented. The Director of Nursing Services confirmed that wound care competencies are conducted by the Infection Preventionist or themselves, but there was no documentation of these observations.
Non-compliance with Building Construction Type Requirements
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101: 19.1.6.1, which limits existing health care occupancies to specific building construction types. The nursing home building is a four-story Type II (000) construction, which exceeds the allowed two stories for this type of construction and requires complete automatic sprinkler protection. During the recertification survey, it was observed that while the elevator room and mechanical rooms on the first floor have protected steel beams, the steel beams and ceilings above the drop ceiling on floors two through four remain unprotected. The Administrator acknowledged that the facility had a time-limited waiver, which expired in 2024, and cited the facility's non-profit status as a reason for the delay in obtaining funding to complete the necessary repairs. The facility has made some progress by replacing light fixtures with compliant fire-rated fixtures and starting to replace ceiling tiles in certain areas.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 Immediate Corrective Action Brooklyn United Methodist Church Home is requesting a three (3) year waiver in order to complete the work already in progress to satisfy the K161 citation. Brooklyn United Methodist Church Home, a not-for-profit nursing facility, needed to apply for a loan in order to remedy the K161 deficiency cited in 2022 and simultaneously also applied for a two (2) year time limited waiver, also in order to complete the work necessary to comply with K161. The loan process took more than 18 months for approval, which negatively impacted the start of the project and the time limited waiver, which has since expired. Since the approval of the loan, Brooklyn United Methodist Church Home has fireproofed the steel beams in the electrical room, the mechanical room, and the boiler room. In addition, Brooklyn United Methodist Church Home has replaced all the light fixtures in the facility with compliant fire rated fixtures. Also, it is important to note that all the grids in the facility are fire rated so as to accommodate the installation of fire rated ceiling tiles. Further, the facility has purchased fire rated ceiling tiles and has installed the fire rated ceiling tiles on two (2) quadrants of the fourth (4th) floor. As such, Brooklyn United Methodist Church Home, with a time waiver extension of three (3) years, would be able to complete the required fireproofing of the facility with fire rated ceiling tiles as follows: Year 1 – Complete the Fourth (4th) and Third (3rd) floors Year 2 – Complete the Second (2nd) floor, and Year 3 – Complete the First (1st) floor II. Identification of Other Residents Brooklyn United Methodist Church Home acknowledges that the residents have the potential to be affected by this practice. The facility respectfully states that there is no additional risk to the residents as the facility is fully sprinklered throughout and smoke detectors installed that are supervised by an approved outside entity. III. Systemic Changes All staff will receive in-service education regarding the life safety issues related to this requirement. The facility will conduct an extra fire drill on each shift per quarter until the fireproof ceiling tile work is completed. Additional fire extinguishers will be maintained on each unit of the facility. The Administrator will work to secure a three (3) year waiver. IV. QA Monitoring The Administrator will monitor the status of the waiver request and any progress made in the process of continuing the work to fireproof the facility with fire rated ceiling tiles. The Administrator will provide a written report monthly to the QA committee, and said reports will be reviewed quarterly by the QAPI committee at the quarterly QAPI meetings.
Failure to Conduct Required Emergency Generator Testing
Penalty
Summary
The facility failed to ensure that all required testing and inspection were conducted on its emergency generators, as mandated by the NFPA 101 and NFPA 110 standards. During a review of the emergency generator testing and inspection records, it was found that the facility did not have a record of the three-year, four-hour load test. This test is crucial for ensuring the reliability and functionality of the emergency power supply system (EPSS) in case of a power outage. The deficiency was identified during a document review on January 7, 2025, between 12:00 pm and 1:00 pm. At the exit conference held on the same day, the facility's Administrator acknowledged the oversight and mentioned that a vendor would be contracted to conduct the required test. This indicates a lapse in the facility's compliance with the established standards for emergency power systems, which are critical for maintaining safety and operational continuity in the event of an emergency.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 I. Immediate Corrective Action The Environmental Service Director obtained a proposal from the vendor, National Standby Repair, Inc. to conduct the 3-year 4-hour load test to be conducted. II. Identification of Other Residents Once the required load test is completed, the facility respectfully states that there is no additional risk to the residents; further, there is a co-generation plant in place to provide continuous power to the facility. III. Systemic Changes The maintenance staff will receive additional education related to the life safety issues identified with inspections and testing of the Emergency Generator. Lesson Plan and attendance will be filed for validation. The 3-year, four (4) hour load test for the Emergency Generator will be added to the established Preventative Maintenance and Scheduling program, and all inspection results will be recorded in the building records and logs. The Environmental Service Director will develop an audit tool to track compliance with this requirement. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that all inspection results for the Emergency Generator are recorded. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be reported to the Administrator by the Director of Environmental Service/designee with a correction plan if warranted. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey result reports for the three preceding years were readily available to residents and visitors upon request. During the Recertification survey, it was observed that the survey binder located by the reception area contained only the survey results for the year 2023. Additionally, there was no notice of the availability of these survey results posted in prominent and accessible areas throughout the facility. Interviews with residents during a Resident Council meeting revealed that none of the nine residents knew where the Department of Survey results were posted. Among these residents, six had BIMS scores indicating varying levels of cognitive function, with scores ranging from 12 to 15, suggesting that the majority were cognitively intact or had only moderate impairment. The Director of Activities stated that residents are reminded about the availability of survey results during monthly Resident Council meetings, but acknowledged that there were no postings about the availability of survey results on all units. The facility Administrator admitted to being unaware that the survey results for the three preceding years should be made available to residents and the public, and that notices should be posted in prominent areas throughout the building. This lack of awareness and action led to the deficiency, as the facility did not comply with the requirement to make survey results accessible and visible to residents and visitors.
Failure to Post Actual Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the total number of nursing staff and actual nursing staffing hours were posted in a prominent place readily accessible to residents and visitors. During the Recertification survey, it was observed that staffing postings were placed on a bulletin board in a location that was not accessible to all residents and visitors. The postings documented projected hours for day, evening, and night shifts but did not reflect the actual staffing numbers. The facility's policy required that staffing information be posted within two hours of the beginning of each shift in a clear and readable format, but this was not adhered to. Interviews with the Staffing Coordinator and the Director of Nursing Services revealed a lack of awareness regarding the requirement to post actual staffing numbers and ensure visibility to residents and visitors. The Staffing Coordinator mentioned that staffing is posted every day at 7 AM for all shifts, based on projected needs rather than actual staffing. The Director of Nursing Services and the Administrator were not aware that the postings needed to reflect actual staffing and be visible to residents and visitors, indicating a gap in understanding and implementation of the facility's staffing policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,293 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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-queens Nursing 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Brooklyn United Methodist Church Home.
100% money-back within 48 hours.
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.