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 August 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.
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.
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 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.
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.
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.
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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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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Illustrative
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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 | ★★★★★ | 9 | 0 |
| Crown Heights Center For Nursing And Rehabilitatio | 1.8 mi | ★★★★★ | 5 | 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 August 2026) and official state health department websites.