Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palm Gardens Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not maintain sufficient nursing staffing to meet resident needs, with PBJ data triggering for excessively low weekend staffing and staffing records showing repeated shortages of RNs, LPNs, and CNAs across multiple units and shifts. The facility assessment listed par staffing levels for each floor, but records from the spring and early summer showed frequent understaffing on the 2nd through 7th floors. The Staffing Coordinator and DON stated call-outs, resignations, double shifts, and agency use contributed to the shortages, and that the facility sometimes worked short.
In the kitchen, the FSD and multiple dietary staff were observed preparing and handling food while wearing baseball caps or no hair restraint, with hair sticking out or uncovered. Facility policy required hairnets or hair restraints to fully cover all hair, but staff said they believed baseball caps were acceptable because they saw the FSD wearing one. The Administrator stated the staff were not wearing appropriate hair coverings while preparing food for residents.
Meals were routinely served to residents on one unit in disposable foam containers with plastic cutlery instead of standard dishware. Staff said this practice had continued since the COVID-19 pandemic, including for pureed diets, and interviews confirmed it had become the normal method of meal service for years. Several residents with varying levels of cognitive impairment and eating assistance needs were affected, and there was no documented medical or behavioral reason for the use of disposable dishware for some of them.
A resident receiving continuous oxygen for heart failure and hypertension was repeatedly observed with an undated nasal cannula attached to the concentrator. The resident could not recall when the tubing was last changed, an LPN did not know when it had last been changed, and an RN confirmed the tubing should be changed and dated but could not explain why it was undated. The DON stated tubing should be dated when changed, but unit rounds did not include checking nasal cannula tubing.
A resident with larynx CA, HF, seizure disorder, depression, and schizophrenia did not have documented evidence of the required monthly pharmacist medication regimen review, including chart review, for one month. The resident was receiving psychotropic meds, insulin, and an anticonvulsant. The Consultant Pharmacist stated the chart was reviewed and no irregularities were found, but the review was not documented in the medical record, and the DON was unsure why it was missed.
Survey results were kept in a binder at the lobby security station, but notices directing residents and the public to that location were not posted on any of the six resident floors. During a Resident Council meeting, most residents said they did not know where to find the survey results and had not seen any notice, and prior council minutes did not show that residents were informed of the location.
Incomplete and Infrequent Daily Nurse Staffing Posting: The facility failed to post daily nurse staffing information as required. A staffing sheet in the lobby listed RNs, LPNs, and CNAs, but did not include the resident census or the total number and actual hours worked by nursing staff. Staff interviews showed the posting was not updated daily, weekend postings were missed, projected rather than actual hours were used, and the staffing records were being discarded instead of retained.
A resident with severe cognitive impairment was involved in an incident where an LPN pulled them into an elevator, resulting in the resident falling. The incident was witnessed by several staff members, and video footage confirmed the events. The facility's policy on abuse was not adhered to, as the LPN's actions posed a potential for harm.
A facility failed to report a CNA administering medications without a license to the NYSDOH within 24 hours and did not notify local law enforcement. The incident involved 15 residents, many with severe cognitive impairments, and the CNA accessed the eMAR to administer 106 medications. The facility's policy required prompt reporting of such incidents, but the DON and Administrator misunderstood the reporting requirements.
A CNA at a facility administered medications to 15 residents without a nursing license, violating New York State Education Law and facility policy. The CNA was mistakenly allowed to perform LPN duties, including administering critical medications, due to a lack of verification by the supervising RN. This incident involved residents with severe cognitive impairments and complex medical conditions.
Insufficient Nursing Staffing and Repeated Unit Shortages
Penalty
Summary
The facility did not ensure sufficient nursing staff were available to meet resident needs and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The deficiency was identified during recertification survey review of staffing records and interviews, which showed that actual staffing levels were not maintained at the par levels listed in the facility assessment. The facility policy stated staffing levels were to be adequate to provide nursing care to residents 24/7, but the Payroll Based Journal Staffing Data Report for FY Quarter 3 2025 triggered for excessively low weekend staffing. The Facility Assessment Tool dated 09/2025 listed required staffing levels for each unit and shift, including RNs, LPNs, and CNAs for the 2nd through 7th floors. Review of staffing information from April through June 2025 documented repeated shortages across multiple shifts and units. Examples included shortages of RNs, LPNs, and CNAs on the 2nd, 3rd, 4th, 5th, 6th, and 7th floors on numerous dates, with some shifts showing multiple unit shortages at the same time. The staffing records showed these shortages occurred on day, evening, and night shifts and were especially frequent on weekends. During interviews, the Staffing Coordinator stated that the facility checked for sick calls each morning, tried to find replacements, and sometimes moved CNAs between floors depending on census, but a replacement could not always be found and the facility sometimes worked short. The Staffing Coordinator also stated that between April and June 2025 the facility had been working short because RNs and CNAs were leaving or resigning, staff were doing double shifts, and more agency staff were used, but call-outs still occurred at the last minute. The DON stated the facility had the same amount of staffing on weekends as during the week, but call-outs and vacations made replacement difficult, especially when there were more than three call-outs. The DON also stated the facility used weekend staff, double shifts, and 11 contracted agencies, while continuing to recruit staff.
Inadequate Hair Restraints in Kitchen Food Preparation
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety because dietary staff were observed in the kitchen without appropriate hair restraints. During the kitchen task, the Food Service Director was seen wearing a baseball cap with some hair sticking out, and [NAME] #1, Dietary Aide #1, and Dietary Aide #2 were each observed wearing baseball caps with hair not fully restrained and sticking out from under the caps while assisting with wrapping tuna sandwiches or standing near an open pot on the stove. Dietary Aides #3 and #4 were also observed near the kitchen door carrying food containers without any hair restraint, despite a box of hair nets being available at the kitchen entrance. The facility policy stated that all dietary employees working in the dietary department must wear a hairnet or hair restraint that covers all hair, including facial hair. Interviews showed the Food Service Director said they always wore a baseball hat and did not realize some hair was not covered, and staff stated they believed baseball caps were acceptable because they saw the Food Service Director wearing one. The Administrator stated the kitchen staff were not wearing appropriate hair coverings while preparing food for residents, which was not acceptable.
Meals Served in Disposable Foam Dishware
Penalty
Summary
The facility failed to ensure that residents were treated with respect, dignity, and care in a manner that promotes quality of life and recognizes individuality when meals were routinely served on the 7th floor in disposable foam containers with disposable plastic cutlery. During observations of lunch service, meal trays were seen arriving on the unit with white foam 3-compartment containers, plastic utensils, foam cups, and foam bowls holding soup and liquids. Additional observations showed more meals plated in foam containers, with residents using plastic utensils and drinking from foam cups and bowls, while some meals were also plated on ceramic plates. The affected residents included six residents on the unit, including residents with moderate to severe cognitive impairment and varying levels of assistance needed for eating. The record stated there was no documented evidence that several of the residents required plastic or disposable dinnerware for medical or behavioral reasons. One resident was documented as cognitively intact and requiring partial/moderate assistance with eating, while others were documented as needing dependent assistance, supervision, or touching assistance with eating. A resident interviewed during the survey stated that this was the way meals were served at the facility. Staff interviews confirmed that disposable dishware and utensils had been used routinely for years. A CNA stated residents always used plastic forks and ate out of plastic containers, and that residents who required chopped or pureed food received meals in plastic containers. An RN stated soup, hot cereal, water, and meals had always been served in plastic or foam items and suggested it may be for safety reasons. The Food Service Director stated the facility had used disposable dishware and utensils since the COVID-19 pandemic, including for pureed food, contact isolation, and visitors. The DON stated they were not sure why the facility continued to use disposable food items, and the Administrator stated the residents had requested this because pureed foods were mixing together on regular plates, but no complaints had been made about the disposable items.
Undated oxygen tubing for resident receiving continuous oxygen
Penalty
Summary
The facility did not ensure safe and appropriate respiratory care for a resident receiving continuous oxygen therapy. Resident #33 had diagnoses including heart failure and essential hypertension, was cognitively intact, and had a physician’s order for oxygen via nasal cannula at 2 liters per minute continuously. The care plan directed staff to provide oxygen as ordered and teach oxygen conservation techniques. During survey observations, the resident was repeatedly seen resting in bed with an undated nasal cannula attached to the oxygen concentrator beside the bed while receiving oxygen at the ordered rate. The resident stated they could not recall when the nasal cannula was last changed. An LPN stated the tubing had to be changed every three days and did not know when it was last changed, while an RN stated the tubing was to be changed and dated weekly on Sunday night or per doctor’s order for infection control purposes. The RN observed the undated tubing with the surveyor and could not explain why it was undated. The DON stated tubing should be dated when changed so staff would know when it was due next, and also stated unit rounds did not include checking nasal cannula tubing.
Missing Monthly Pharmacist Medication Regimen Review
Penalty
Summary
The facility did not ensure that a licensed pharmacist completed a monthly drug regimen review for each resident, including review of the medical chart, as required by its policy. This was identified for one resident out of the sampled records reviewed, where there was no documented evidence that the medication regimen review was completed in August 2025. The facility policy stated that the drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist and that the review must include the resident’s chart, including for residents receiving psychotropic medications. The resident involved had diagnoses including larynx cancer, heart failure, seizure disorder, depression, and schizophrenia. The resident’s assessment documented moderate impairment and use of antipsychotic, antianxiety, antidepressant, antiplatelet, hypoglycemic, and anticonvulsant medications. Physician orders included risperidone, insulin, and venlafaxine. Pharmacy progress notes were present for March, April, May, June, July, and September 2025, but there was no documented evidence of a pharmacy review in August 2025. During interview, the Consultant Pharmacist stated they were responsible for monthly medication reviews, said they had looked at the resident’s chart and found no irregularities, but forgot to document the review in the medical record. The DON stated the pharmacist comes every month and was not sure why the resident’s review was missed.
Survey Results Notice Not Posted on Resident Floors
Penalty
Summary
The facility did not ensure that notice of the availability of the most recent survey results was posted in prominent and accessible areas for residents and the public. During observations on multiple dates, survey results were found in a binder at the security station in the lobby, but there were no posted notices on any of the six resident floors directing residents or visitors to where the survey results could be found. During the Resident Council meeting, ten residents attended and nine stated they did not know where to find the survey results and had not seen any notice telling them where to locate them. The Resident Council meeting minutes from prior months did not document that residents were informed about where to locate survey results. The Administrator stated that signage had been posted by the elevators on all six resident floors, but also said recent wall painting may have caused the signs to fall off, and the Administrator and surveyor were unable to locate any such signage on the resident floors.
Incomplete and Infrequent Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted as required. During the recertification survey, a Daily Staffing sheet dated 09/12/2025 was observed posted in the lobby on 09/14/2025, but it did not include the resident census or the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The facility policy titled Staffing Level stated that nurse staffing information was to be posted detailing the number of licensed nursing staff, including RNs, LPNs, and nurse's aides, on duty for every shift every day. Interviews with facility staff showed that the staffing posting was not being maintained daily and was not being completed accurately. The DON stated the posting had not been updated since 09/12/2025 because the Staffing Coordinator was not in the building on weekends. The Staffing Coordinator stated they were responsible for posting projected hours and projected staff numbers, did not include the census, entered projected rather than actual hours worked, and had been discarding staffing posting information instead of keeping it for at least 18 months. The HR Assistant stated they were told to prepare the staffing sheet with staff numbers and hours, but did not have access to the EMR to obtain the census and did not post the Daily Staff information when the Staffing Coordinator was off on weekends.
Resident Abuse Incident Involving LPN
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Licensed Practical Nurse (LPN) and a resident. On the evening of March 19, 2025, the LPN, returning from a break, encountered the resident in the first-floor lobby. The resident, who was severely cognitively impaired and had a history of aggressive behavior, was being verbally redirected by other staff members. Despite the resident's combative state, the LPN took the resident's hand and pulled them towards and into the elevator, resulting in the resident tumbling and sitting on the elevator floor. The incident was witnessed by several staff members, including Certified Nursing Assistants (CNAs), a Security Guard, and a Registered Nurse Supervisor. The facility's video surveillance footage corroborated the sequence of events, showing the LPN pulling the resident into the elevator and the resident falling. The resident was then pulled along the floor out of the elevator on their designated floor. The staff present did not physically intervene, and the Registered Nurse Supervisor later stated that they were in shock at the rapid unfolding of events. The resident, who was admitted with a diagnosis of severe cognitive impairment, did not recall the incident and denied any pain when assessed later. The facility's policy on abuse, mistreatment, neglect, and exploitation was in place to prevent such occurrences, but the actions of the LPN were contrary to these guidelines. The policy emphasized that abuse does not have to be intentional and can be considered abuse if there is potential for harm, which was evident in this situation.
Failure to Report Unauthorized Medication Administration
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act. On 07/10/2023, the Administrator and the Director of Nursing received a report that a Certified Nursing Assistant (CNA) administered medications to 15 residents without a nursing license. The facility reported the incident to the New York State Department of Health (NYSDOH) on 07/14/2023, four days after the incident occurred, which was not within the required 24-hour timeframe. Additionally, the facility did not report the incident to local law enforcement as required. The report highlights that the facility's policy, titled 'Reporting Abuse to State Agencies and Other Entities/Individuals,' mandates that all alleged or suspected violations or crimes be promptly reported to appropriate state agencies and other entities as required by law. Despite this policy, the facility did not adhere to the required reporting procedures. The Director of Nursing stated that they were unaware of the requirement to report the incident to local law enforcement and believed they had five days to report to the NYSDOH, not 24 hours. The incident involved 15 residents, many of whom were severely impaired in cognition, with diagnoses including respiratory failure, tracheostomy, diabetes, and other serious conditions. The CNA used their username and password to access the electronic Medication Administration Record (eMAR) and administered a total of 106 medications. The facility's investigation concluded that the CNA posed as a nurse and provided care to residents, leading to their termination. However, there was no documented evidence of abuse, neglect, or mistreatment of the residents.
Unauthorized Medication Administration by CNA
Penalty
Summary
The facility failed to comply with New York State Education Law and its own medication administration policy, resulting in a Certified Nursing Assistant (CNA) performing duties reserved for licensed nursing staff. On July 10, 2023, CNA #1 identified themselves as a Licensed Practical Nurse (LPN) and was permitted by Registered Nurse Supervisor #1 (RNS #1) to administer medications to residents, despite not holding a nursing license. This action was in direct violation of the New York Education Law Section 6512, which prohibits unauthorized practice of a profession, and Section 6509, which defines professional misconduct as allowing an unlicensed person to perform activities requiring a license. The incident involved 15 residents, all of whom received medications from CNA #1 during the evening shift. The electronic Medication Administration Record (eMAR) documented that CNA #1 administered various medications, including insulin, heparin, and other critical drugs, to residents with severe cognitive impairments and complex medical conditions such as tracheostomy, diabetes, and respiratory failure. The facility's policy clearly states that only licensed Registered Nurses (RNs) and LPNs are authorized to prepare, administer, and record medications, yet this policy was not adhered to. Interviews revealed that RNS #1 did not verify CNA #1's credentials or check the staffing schedule, leading to the unauthorized administration of medications. CNA #1 admitted to working as a nurse without a license and administering medications, including narcotics, to residents. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that staff verification procedures were not followed, contributing to the breach of professional standards and regulations.
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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) |
|---|---|---|---|---|
| Caton Park Rehabilitation And Nursing Center, Llc | 0.6 mi | ★★★★★ | 1 | 0 |
| Ditmas Park Care Center | 0.8 mi | ★★★★★ | 0 | 0 |
| The Monarch At Brooklyn Rehab And Nursing Center | 1.3 mi | ★★★★★ | 8 | 0 |
| The Heritage Rehabilitation And Health Care Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Boro Park Center For Rehabilitation And Healthcare | 1.4 mi | ★★★★★ | 0 | 0 |
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