Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buena Vida Rehab And Nursing Center during CMS and state inspections, most recent first.
Insufficient Nursing Staffing: The facility failed to maintain staffing levels consistent with its own assessment and policy, with interviews, PBJ data, and schedule reviews showing repeated nurse and CNA shortages across multiple units and shifts. The records documented ongoing understaffing on day, evening, and night shifts, including weekends, with several floors short one or more nurses and CNAs at the same time.
Failure to develop comprehensive care plans affected three residents: one resident receiving hemodialysis had no dialysis care plan despite orders and readmission documentation, one resident with severe cognitive impairment and behavioral issues had no care plan addressing head banging or related interventions, and one resident on continuous O2 via NC had no documented oxygen care plan. RN and DON interviews confirmed the omissions, and the DON cited RN staffing shortages and turnover as affecting documentation compliance.
Care plans were not reviewed and revised after assessments for four residents. One resident’s depression plan was not updated after a significant change assessment, another resident’s oxygen therapy plan still referenced nebulizers despite current oxygen use, a third resident’s abuse risk plan was not updated after a quarterly assessment showing severe cognitive impairment, and a fourth resident’s advance directives plan did not reflect a feeding tube documented in the assessment, orders, and MOLST. Interviews with the DON, DOSS, RN, and SW confirmed the missed updates and documentation gaps.
Facility environment not maintained in clean, safe, and homelike condition. Surveyors found widespread damage and poor upkeep across multiple units, including dirty surfaces, peeling and chipped paint, torn and stained wallpaper, missing floor and shower tiles, stained ceilings, exposed wiring, and damaged nurses’ station furnishings. Staff reported some issues were deferred for future renovations, while a resident said an overbed light pull cord was too short to use independently and another said a damaged pull cord had been present since admission.
Improper Dating and Labeling of Stored Food Items: Surveyors found multiple prepared and frozen food items in the kitchen with illegible, missing, or inconsistent dates and labels, including cooked items, biscuits, bagels, bread, raw eggs, raw meat, fruit, waffles, hamburger buns, and meat patties. Dietary staff gave conflicting statements about how long opened or prepared foods could be kept, and the FSD described different timeframes for opened items, stuffed peppers, raw meat, and boiled eggs.
A facility failed to notify and involve a resident’s representative in a significant Seroquel dose reduction. The resident had Alzheimer’s disease, psychotic disorder, depression, anxiety, and severe cognitive impairment, and the antipsychotic was tapered after a psych consult and provider review. The facility could not produce documentation showing the representative was informed or consulted before the med change, and interviews confirmed the representative was not notified.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was repeatedly observed positioned between the elevated head and foot sections of a bed that was placed against a wall. The facility had no documentation of medical necessity, physician authorization, restraint assessment, ongoing reevaluation, or informed consent for the bed placement, while the resident’s representative, CNA, RN, and DON all described the positioning and the facility’s lack of restraint-related documentation.
The facility failed to report two investigated events to DOH: one resident with severe cognitive impairment had an unexplained forehead injury, and another resident with severe cognitive impairment was found on the floor with an acute hip fracture after an unwitnessed fall. In both cases, staff could not establish the cause of the injury, but the DON and Administrator determined the events did not meet reporting criteria and did not notify DOH.
A resident with DM, malnutrition, and moderate cognitive impairment reported a broken tooth and pain with eating, but the dental consult ordered for tooth decay was not completed in a timely manner. Staff and the dental consultant were unsure why the resident was not seen sooner, and the missed dental visit was not documented or communicated to the unit.
Improper Disposal of Garbage and Refuse: The facility failed to keep the outside dumpster properly contained. Staff observed an uncovered 20-yard dumpster that was overfilled with exposed garbage and multiple flies around the bags. Dietary and housekeeping staff said the dumpster did not have a lid or cover, and facility leaders stated pickup had been increased after the compactor was replaced during construction, but garbage still piled up when waste collection was missed because the driveway was blocked.
A resident experienced persistent diarrhea and significant weight loss while receiving tube feedings. The facility failed to provide adequate medical follow-up or increased weight monitoring, despite multiple formula changes and ongoing gastrointestinal distress.
The facility failed to report a resident's dislocated right shoulder of unknown origin within the required 2-hour timeframe. The resident, who was severely cognitively impaired, was found in pain and later transferred to the hospital. Both the DON and Administrator were unaware of the incident and reporting requirements.
Insufficient Nursing Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and to help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. The deficiency was based on observation, record review, and interviews with residents, resident representatives, and staff members, which indicated ongoing staffing concerns in the facility. The facility policy titled Staffing, last reviewed 04/31/2026, stated that the facility must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety. The policy also stated that providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident needs. The Facility Assessment, last updated 06/01/2026, documented staffing par levels for each shift and unit, including 2-4 nurses and 4-5 CNAs per unit on day shift, 2-3 nurses and 4-5 CNAs per unit on evening shift, and 2-4 nurses and 4-5 CNAs per unit on night shift. Review of actual staffing schedules from 01/01/2026 through 06/12/2026 showed multiple dates and shifts where staffing fell below the facility assessment levels. The report lists repeated shortages across multiple floors and shifts, including nurses and CNAs missing on day, evening, and night shifts. The Payroll Based Journal Staffing Data Report for 01/01/2026-03/31/2026 also triggered for excessively low weekend staffing. The documented shortages included numerous instances where several units were short one nurse, one CNA, or both, and on some dates multiple units were short staff at the same time.
Failure to Develop Comprehensive Care Plans for Dialysis, Behavioral, and Oxygen Needs
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans to address the medical and behavioral needs of three residents. The report states that the comprehensive care plan was not developed for a resident with end stage renal disease who was receiving hemodialysis, was not created for a resident with severe cognitive impairment who exhibited self-injurious and resistive behaviors, and was not created for a resident receiving continuous oxygen therapy for acute respiratory failure and pneumonia. For the resident receiving dialysis, the record showed an annual MDS documenting moderately impaired cognition and dialysis treatment, a patient review instrument documenting hemodialysis three times weekly, an admission nursing note stating the resident had returned from the hospital after two cycles of hemodialysis and was to resume the regular schedule, and a physician order for hemodialysis three times a week. The comprehensive care plans initiated on admission did not include a dialysis plan. The admitting RN stated the dialysis care plan was missed, and the DON stated the resident had been going to dialysis three times a week and the care plan should have been implemented upon readmission. For the resident with Alzheimer’s disease, psychotic disorder, depression, and anxiety disorder, the quarterly MDS documented severe cognitive impairment and that the resident was rarely or never understood, and the occurrence investigation documented resistive and combative behaviors during care as well as head injury findings after staff observed a bump and discoloration on the forehead. The existing care plan addressed rolling from side to side in bed but did not address head banging behavior or related interventions. For the resident receiving oxygen, the quarterly MDS documented continuous oxygen therapy and the physician ordered oxygen at 2 liters per minute via nasal cannula for shortness of breath, but there was no documented evidence that an oxygen care plan had been initiated. Staff and the DON stated the admission nurse initiates care plans, and the DON stated staffing shortages and RN turnover affected documentation compliance.
Care Plans Not Reviewed After Assessments
Penalty
Summary
The facility failed to ensure that residents’ comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including comprehensive and quarterly assessments. Surveyors identified four residents whose care plans were not updated to reflect assessment findings: a resident with depression, a resident receiving oxygen therapy, a resident at risk for abuse, and a resident with an advance directives care plan that did not match the resident’s current feeding tube status. For the resident with depression, the record showed diagnoses including anxiety disorder and depression, an antidepressant order for sertraline, and a care plan for antidepressant use that had last been reviewed before a later significant change assessment. Documentation included nursing and psychology notes, but there was no evidence the depression care plan was reviewed or revised after the significant change assessment. For the resident receiving oxygen therapy, the record showed diagnoses including coronary artery disease, Alzheimer’s disease, and respiratory failure, with assessments documenting oxygen therapy. The care plan referenced oxygen therapy and nebulizer treatments, but it had not been reviewed or revised after later assessments and still included nebulizer-related interventions even though the resident was no longer on nebulizers. For the resident at risk for abuse, the quarterly assessment documented severe cognitive impairment and total dependence for care, while the abuse care plan had last been revised months earlier and had no evidence of review after the assessment. For the resident with advance directives, the quarterly assessment documented severe cognitive impairment and a feeding tube, and the physician orders and MOLST form documented a long-term feeding tube, but the advance directives care plan still stated no feeding tube. Interviews with the DON, Director of Social Services, RN, and Social Worker confirmed that care plans were not being documented as reviewed or revised after assessments and that staffing and workload issues affected documentation compliance.
Facility Environment Not Maintained in Clean, Safe, and Homelike Condition
Penalty
Summary
The facility failed to ensure residents lived in a clean, comfortable, and homelike environment. Observations on multiple resident care floors found damaged walls and wallpaper, peeling and chipped paint, stained ceilings, missing floor and shower tiles, dirty surfaces, damaged resident room fixtures, and deteriorated nurses’ station furnishings. The cited policy required a comprehensive preventive maintenance program to maintain a safe, functional, sanitary, and comfortable environment, and the cleaning policy required resident rooms to be cleaned regularly with daily cleaning, disinfecting, dusting, floor cleaning, garbage removal, and inspection of furnishings. On Unit 3, surveyors observed dirty heating/cooling units, radiators, windowsills, walls, and wall guards with brown and black debris; holes and black scuff marks in hallway walls; chipped and peeling paint on walls, door frames, elevator doors, and bathroom ceilings; peeling paint on bathroom wall tiles and discolored grout; ceiling stains in resident rooms and common areas; cracked floor tiles; a wall opening above the staff lounge with exposed wiring; a partially detached, non-functioning Rauland call bell without a pull string; and drip stains on lounge walls with chipped wall borders. A resident stated the overbed light pull cord was too short to independently operate the light and wanted the light repaired and the wall repainted. Another resident’s overbed light pull cord was observed damaged and repaired with rolled plastic material, and the resident stated it had been that way since admission. On Units 4, 5, and 6, surveyors observed hallway wallpaper with food stains, pen marks, tears, white painted patches, discoloration, and heavy wear; resident room floors with visible footprints, wheelchair tracks, and accumulated dirt outside multiple rooms; and a shower room with nine missing floor tiles near the drain. Additional concerns included white spackle patches, missing and damaged wood veneer, brown staining, accumulated debris, dirty and peeling gates, torn and missing wallpaper, exposed wiring near a wall-mounted computer tablet, a room nameplate secured with tape, torn wall covering around nameplates, and stained ceiling tiles. Housekeeping and nursing staff stated some issues were tied to future renovations, that repairs were entered into maintenance systems or verbally reported, and that some conditions had no active work orders documented in the maintenance log.
Improper Dating and Labeling of Stored Food Items
Penalty
Summary
Food items in the kitchen were not stored, prepared, distributed, and served in accordance with professional food service standards because multiple prepared and frozen items were found without legible labels and/or proper dates. During the kitchen tour, surveyors observed items in the walk-in freezer, walk-in refrigerator, bread freezer, and reach-in freezer that were either not dated, had illegible dates, or had dates that did not clearly identify when the items were opened, prepared, or should be discarded. Examples included cooked items in clam shell containers with unreadable dates, unbaked biscuits and bagels with dates that were not legible or inconsistent, cinnamon raisin bread dated 5/8/26, raw eggs and raw meat containers dated 6/1/26, 6/5/26, and 6/6/26, sliced fresh fruit dated Jun 01 26 and Jun 04 26, unbaked waffles labeled open 5/3/26, an opened package of hamburger buns with an illegible date, and an opened box of meat patties labeled 5/21/26. Surveyor interviews showed inconsistent understanding among dietary staff about how long opened or prepared foods could be kept. One dietary staff member stated frozen food items are opened, wrapped, dated when opened, and used within three days, while another stated frozen foods are re-wrapped and dated after opening and used within two days. The Dietary Supervisor stated cooks are responsible for wrapping, dating when opening or preparing, storing, and using items within 24 hours, and also stated stuffed peppers were stored in the freezer for later use and were good for three months. The Food Service Director stated opened items are wrapped, dated with an open date, stored in the freezer, and used within three months; stuffed cabbage/peppers are used within 14 days; raw meat is panned and dated when prepared; boiled eggs are marked with a production date and used within 24 hours. The Food Service Director also stated unopened turkey bacon packages were removed from the original box and that the distributor confirmed frozen turkey bacon received with a manufacturer use-or-freeze-by date had been frozen before delivery to the facility.
Failure to Notify Resident Representative of Antipsychotic Dose Reduction
Penalty
Summary
The facility failed to ensure the designated resident representative was notified of and involved in a significant medication change for one resident. Resident #56 had diagnoses including Alzheimer's Disease, Psychotic Disorder, Depression, and Anxiety Disorder, and the Quarterly MDS documented severe cognitive impairment, that the resident was rarely or never understood, and rarely or never understood others. The assessment also documented that the resident received an antipsychotic medication. A psychiatry consultation recommended tapering the resident's Seroquel from 25 mg three times daily to 12.5 mg three times daily, and the recommendation was reviewed by an RN and agreed to by a PA. The medication was then changed on 01/26/2026, but the facility could not provide documentation showing that the resident's representative was notified of, consulted regarding, or agreed to the dosage reduction before it was implemented. During interviews, the representative stated the facility decreased the dose without consulting them and that they would not have agreed to the reduction, while the psychiatrist, PA, and DON each stated they could not verify that notification occurred.
Bed Placement Used Without Restraint Documentation
Penalty
Summary
The facility failed to ensure a resident was free from the use of physical restraints when Resident #56 was repeatedly observed positioned in the middle of the bed with the head and foot sections elevated and the bed placed against a wall. Resident #56 had diagnoses including Alzheimer's disease, psychotic disorder, depression, and anxiety disorder, and the MDS documented severe cognitive impairment, dependence on staff for all activities of daily living, and no physical or verbal behavioral symptoms. The facility did not have documentation supporting the medical necessity for the bed’s placement against the wall, physician authorization, assessment of restraint use, ongoing reevaluation, or documentation that the resident’s representative had been informed of the risks and benefits of the bed placement. During multiple observations, the resident was seen with the feet resting on a fall mat while positioned between the raised sections of the bed, and the left side of the bed remained against the wall. The resident’s representative stated they frequently found the resident positioned uncomfortably in bed and had previously seen the resident between the elevated head and foot sections, though they preferred the bed remain against the wall due to concern about falls. CNA #4 stated the resident could not operate the bed controls independently and that another staff member may have placed the resident in that position while feeding breakfast. RN #6 stated the resident should not have been left in that position and acknowledged that placing a bed against a wall could be considered a restraint, while the DON stated the facility did not complete restraint-related assessments or documentation for beds positioned against walls because the facility did not consider the practice to be a restraint.
Failure to Report Injuries of Unknown Origin and Unwitnessed Fall
Penalty
Summary
The facility failed to report alleged abuse or injuries of unknown origin to the New York State Department of Health within the required timeframes. The facility’s policy stated that all incidents, complaints, and injuries of unknown origin must be investigated and that the Department of Health must be notified whenever abuse cannot be ruled out. Surveyors identified two residents in the sample whose events were investigated but not reported: one resident with Alzheimer’s disease, psychotic disorder, depression, and anxiety disorder, and severe cognitive impairment, and another resident with schizophrenia, cerebral infarction, non-Alzheimer’s dementia, severe cognitive impairment, and impaired memory. For the first resident, staff observed a bump with yellow discoloration on the left forehead, but the resident could not explain how the injury occurred. The resident was sent to the hospital, where a CT scan showed no acute findings. The investigation concluded the injury was unavoidable and would not be reported, even though the DON later acknowledged there was no documentation of head-banging behavior, no documentation of when the injury occurred, and no evidence establishing the cause of the injury. For the second resident, staff found the resident on the floor beside the bed, the resident complained of hip pain and headache, could not recall the event because of baseline confusion, and x-rays showed an acute left hip fracture. The investigation listed the cause as undetermined and concluded the incident would not be reported, while the DON and Administrator stated the facility believed the fracture was related to the resident’s history of falls and existing interventions rather than an event requiring reporting.
Delayed Dental Evaluation for Resident with Broken Tooth
Penalty
Summary
The facility failed to ensure timely dental care for a resident who had diagnoses including Type 2 Diabetes and malnutrition and who had moderate cognitive impairment with setup assistance needed for eating and oral hygiene. A nursing note documented on 05/08/2026 that a dental consult was ordered for tooth decay on the left molar, but there was no documented evidence that the resident was seen and evaluated by a dentist in a timely manner. During interview on 06/07/2026, the resident stated they had broken one of their teeth about a month earlier, had notified staff, had not yet been seen by a dentist, and had pain when eating. Facility staff and the dental consultant gave inconsistent accounts of follow-up on the consult. An RN stated the dentist typically came weekly or every other week and was unsure why the resident had not been seen during the prior month. The DON stated residents with non-urgent dental complaints should be seen within a week and reported that the dentist said they attempted to visit the resident on 05/20/2026 but the resident was not in the room. The dental consultant stated they did not document the missed visit, did not notify staff, and planned to treat the concern symptomatically and reattempt the visit if symptoms continued. The resident was not assessed by the dentist until 06/09/2026, when the resident was determined to require an off-site tooth extraction.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure garbage and refuse were disposed of properly. During observations of the outside garbage disposal area, the 20-yard dumpster was seen overfilled with piled garbage exposed and multiple flies around the garbage bags. The dumpster was also observed without a cover or lid, and on a later observation it remained uncovered with multiple flies surrounding it. Facility staff stated the dumpster was being used by dietary and housekeeping staff and could become filled when garbage was not picked up as scheduled. The Food Service Director, Housekeeping Director, and Administrator each stated the facility had recently switched from a compactor to the 20-yard dumpster because of construction, that the dumpster did not come with a lid or cover, and that pickup had been increased to keep garbage from piling up. Staff also stated the dumpster was overfilled after waste could not be picked up because the driveway entrance was blocked.
Failure to Prevent Complications of Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means receives the appropriate care and services to prevent complications of enteral feeding. Resident #1 experienced persistent diarrhea from March 2023 to October 2023 while receiving tube feedings and suffered a significant weight loss of over 20 percent. Despite these issues, there was no documented evidence that additional medical follow-up was attempted when the facility was unable to identify a cause for the persistent diarrhea or that increased weight monitoring was implemented when Resident #1 experienced significant weight loss. Resident #1 was admitted with multiple diagnoses, including cerebral infarction, aphasia, dysphagia, and hemiplegia, and had a feeding tube. The resident's weight was recorded as 138 pounds upon admission, but subsequent weights showed a significant decline, reaching as low as 100 pounds. The facility's documentation revealed numerous bouts of loose stool over several months, yet there was no evidence of a referral for additional evaluation or increased monitoring of the resident's weight. Interviews with the medical doctor and review of medical progress notes indicated that the resident's tube feeding formula was changed multiple times due to gastrointestinal distress and a national shortage of tube feeding formulas. Despite these changes, the resident continued to experience diarrhea and weight loss. The medical doctor acknowledged that the resident's condition was complicated by multiple comorbidities and a non-healing surgical wound, which also contributed to the weight loss. However, the facility did not take adequate steps to address the persistent diarrhea and significant weight loss effectively.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility did not ensure that all alleged violations involving injuries of unknown source were reported immediately to the New York State Department of Health, as required. Specifically, the facility failed to report a resident's dislocated right shoulder of unknown origin within 2 hours of the occurrence. The incident involved a resident with diagnoses of osteoarthritis, dementia, and hypertension, who was severely cognitively impaired and required assistance from two people for activities of daily living. The resident was found screaming in pain by a Certified Nursing Assistant, and a subsequent medical examination confirmed a right shoulder dislocation, leading to the resident's transfer to the hospital. The facility's policy mandates reporting any suspected abuse, neglect, mistreatment, or misappropriation of property to the New York State Department of Health. However, the facility reported the injury more than 2 hours after the occurrence, as documented in the Aspen Complaint Tracking System. Interviews with the Director of Nursing and the Administrator revealed that both were unaware of the incident and the reporting requirements, indicating a lapse in compliance with the mandated reporting timeframe.
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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) |
|---|---|---|---|---|
| Concord Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 18 | 0 |
| Brooklyn Gardens Nursing & Rehabilitation Center | 1.3 mi | ★★★★★ | 4 | 0 |
| Bedford Center For Nursing And Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| Brooklyn Center For Rehabilitation And Residential | 1.7 mi | ★★★★★ | 4 | 0 |
| Crown Heights Center For Nursing And Rehabilitatio | 1.8 mi | ★★★★★ | 5 | 0 |
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