Brooklyn Center For Rehab And Residential Health C

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

facility when the incident with Resident #2 occurred. The Director of Nursing also stated a stat x-ray was ordered on 09/05/2025 at 1:58 PM, and the facility received the results on 09/05/2025 at 10:55 PM, and it was reviewed by the supervisor on duty at that time. Attempts to contact the physician were unsuccessful until the morning of 09/06/2025 when the physician ordered to send the resident to the hospital on [DATE REDACTED].

The Director of Nursing further stated the incident was reported to the Department of Health on 09/06/2025 because that was when the x-ray results were received.

On 11/03/2025 at 12:48 PM, the Regional Director of Nursing was interviewed and stated the incident occurred on 09/05/2025 and stat x-ray was ordered, and they thought the x-ray result was reported on the same day. The Regional Director of Nursing also stated they were not aware Resident #2 had a fractured hip until the morning of 09/06/2025. The Regional Director of Nursing further stated they submitted the report to Department of Health on 09/06/2025 after Resident #2 was sent to the hospital.

On 11/03/2025 at 2:01 PM, the Medical Director was interviewed and stated they did not receive the call about Resident #2's fracture until the morning of 09/06/2025. The Medical Director also stated the nursing staff did not need their approval and should have notified the Department of Health when the result was received.

On 11/03/2025 at 2:30 PM, Associate Administrator was interviewed and stated they Resident #2's injury should be reported within two hours, and it is the nursing department's responsibility to submit the online report. The Associate Administrator also stated they were not aware the reports had not been submitted on time. 10 NYCRR 415.4(b)(2)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brooklyn Ctr for Rehab and Residential Health Care

170 Buffalo Avenue Brooklyn, NY 11213

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview during the abbreviated survey (#2265750), the facility did not ensure a comprehensive person-centered care plan for each resident was reviewed and revised based on changing goals, preferences and needs of the resident and in response to current interventions. This was evident for one (1) out of five (5) residents (Resident #1) reviewed. Specifically, the comprehensive care plan for Resident #1 was not reviewed or revised after Resident #1 fell from a mechanical lift during transfer and sustained injury. The finding is: The facility policy titled 'Care Plan Comprehensive' reviewed 8/2/2024 documented assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change. Resident #1 had diagnoses which included Heart failure and Anxiety. A review of the Minimum Data Set (a resident assessment tool) dated 10/08/2025 documented Resident #1 had intact cognition, and they required dependent assistance for toileting, showers, and transfers. The Minimum Data Set also documented Resident #1 had no history of falls. On 10/31/2025 at 1:25 PM, the State Surveyor observed Resident #1 sitting in a wheelchair in their room. Resident #1 was wearing a blue sling on their left arm and swelling the size of quarter was observed over the left eyebrow area. Resident #1 denied pain and stated the injury occurred when they fell from the hoyer lift when one (1) staff transferred them without assistance of another staff person. The Hospital Discharge summary dated [DATE REDACTED] documented Discharge Diagnosis: fall fracture of the humerus (disorder). Humerus fracture treated with immobilization follow up with orthopedics in two (2) to three (3) days. Return for any complication. The nursing progress note written by Licensed Practical Nurse #5, dated 10/24/2025 at 9:36 PM, documented resident returned from the Emergency Room, where they transferred for post-fall evaluation. The resident was diagnosed with a humerus fracture (a break in the long bone in the upper arm), which is being treated with immobilization.The care plan titled had an actual fall related to history of falls reviewed on 11/5/2024 with had interventions which included anticipate and meet the resident needs, be sure the resident's call light is within reach and encourage to use it for assistance as needed and provide well-lit environment.There was no documented evidence that the comprehensive care plan was reviewed or revised to include interventions after the fall that occurred on 10/23/2025. On 10/31/2025 at 1:40 PM, Registered Nurse #1 Unit Manger was interviewed and stated they did not know about the incident with Resident #1 until they returned to work on 10/24/2025. Registered Nurse #1 also stated they are responsible for completing and updating all care plans on the unit and that the care plans was updated at

the time of the incident, however they were unable to provide a copy of the updated care plan. On 11/03/2025 at 11: 15 AM, the Director of Nursing was interviewed and stated the Registered Nurses are responsible for initiating, and updating care plans and the Licensed Practical Nurses can update if they discuss this with the Registered Nurses. The Director of Nursing logged into the computer and stated the care plan was not updated. The Director of Nursing further stated the fall Care Plan was last updated on 10/16/2025 prior to the fall and could not explain why the fall care plan had not been updated after the fall incident. 10 NYCRR 415.11(c)(2)(i-iii)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brooklyn Ctr for Rehab and Residential Health Care

170 Buffalo Avenue Brooklyn, NY 11213

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the floor and put them back to bed, and then they immediately went to notify the charge nurse. Certified Nursing Assistant #7 also stated Certified Nursing Assistant #6 did not call them to help assist in use of the mechanical lift for the transfer. Certified Nursing Assistant #7 further stated they were suspended for helping to pick up Resident #3. On 10/31/2025 at 12:15 PM, Certified Nursing Assistant #6 was interviewed and stated they were transferring Resident #3 from the bed to the recliner chair alone when the hoyer lift canvas loosened, and Resident #3 fell out to the floor. Certified Nursing Assistant #7 walked in and assisted them in putting Resident #3 back into the bed. Certified Nursing Assistant #6 stated they decided to transfer Resident #3 alone after trying to find someone to help without any success as the other four (4) Certified Nursing Assistants on the unit were busy with their assigned residents and the two (2) nurses were busy giving medications to the residents. Certified Nursing Assistant #6 stated they knew they should call for another staff to help and they tried to look for someone but could not readily get anyone, and they thought Resident #3 had been in bed too long, so they just went ahead and did it alone to ensure Resident #3 was taken out of bed on time.On 10/31/2025 at 11:26 AM, Licensed Practical Nurse #1 was interviewed and stated they were waiting to assist Certified Nursing Assistant #7 with a resident's shower when Certified Nursing Assistant #7 came to inform them Resident #2 fell when Certified Nursing Assistant #6 was trying to transfer resident from bed by themself with the mechanical lift. The Nurse Manager was immediately notified and assessed Resident #2 after the resident was placed back in bed by the Certified Nursing Assistants. Licensed Practical Nurse #1 stated Certified Nursing Assistant #6 did not call for help before using the mechanical lift to transfer Resident #2 by themselves and failed to notify them before Resident #2 was placed back to bed after the incident. On 10/31/2025 at 11:52 AM, Registered Nurse Manager #1 was interviewed and stated they were on the unit on the day of the incident, and they were called to Resident #2's room around 2:00 PM on 09/05/2025 to assess Resident #2 who reportedly fell during transfer with the mechanical lift. Registered Nurse Manager #1 also stated Resident #2 was already placed back in bed when they got to the resident's room. During assessment, Resident #2 was observed with decreased passive range of motion on the right lower extremity with facial grimacing when gentle passive range of motion was attempted. Registered Nurse Manager #1 further stated they were not informed of the incident

before Resident #2 was placed back to bed. On 11/03/2025 at 12:36 PM, the Director of Nursing was interviewed and stated Certified Nursing Assistant #6 was terminated for not following Resident #2's plan of care, and Certified Nursing Assistant #7 was suspended for not following the facility protocol to notify the supervisor if they observed a resident on the floor.10 NYCRR 415.12

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brooklyn Ctr for Rehab and Residential Health Care

170 Buffalo Avenue Brooklyn, NY 11213

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

such devices used to be visible to them when signing off tasks performed for the residents, but they are no longer seeing those devices in the electronic medical record, and they do not know how to check the instructions when documenting tasks performed in the electronic medical record. On 11/03/2025 at 10:46 AM, Licensed Practical Nurse #4, who was the charge nurse on the unit, was interviewed and stated the instructions on the resident's splint devices are supposed to be visible to the Certified Nursing Assistant in

the Kardex so they know what needs to be done for the residents. Licensed Practical Nurse #4 also stated

they were not aware the Certified Nursing Assistants are not able to view and implement instructions as per

the residents' plan of care. Licensed Practical Nurse #4 further stated they have not seen Resident #2 with any devices because the Certified Nursing Assistant had not been applying it. On 11/03/2025 at 11:49 AM,

the Rehabilitation Director was interviewed and stated that Resident #2 was issued both hand and knee braces to be applied at all times, and to be removed during care for skin check and hygiene care only, and

they were not aware nursing staff had not been applying the devices as recommended. The Rehabilitation Director also stated when they were informed on 11/03/2025 that the devices were not placed on Resident #2, they went to the unit to check and found the two devices were located in Resident #2's closet. The Rehabilitation Director further stated when a device is recommended for a resident, it is given to the nursing staff, documented in the resident care plan and in the electronic medical record Kardex Task for the staff to view the instructions for the device. The Rehabilitation Director stated they usually do audits randomly to see if the device is still in use, and the last audit conducted around 2 years ago indicated Resident #2 had

the devices in place. The Rehabilitation Director also stated it is the responsibility of the nursing staff to ensure the devices are being applied, and if they are missing, to contact Rehabilitation department for replacement. On 11/03/2025 at 11:55 AM, the Director of Nursing was interviewed and stated the task is documented in the Kardex located in the electronic medical record and the Certified Nursing Assistants are supposed to be checking the instructions to know what is to be done for their residents. The Director of Nursing also stated there was no physician's order for the braces because it is a nursing intervention that

the staff need to implement to prevent residents from further contractures. The Director of Nursing further stated the charge nurses and managers on the unit should be monitoring the Certified Nursing Assistants to ensure they are carrying out all tasks as per the residents' plan of care. On 11/03/2025 at 12:05 PM, the Assistant Director of Nursing, who supervised the Licensed Practical Nurses, was interviewed and stated staff are educated and are expected to be monitored and supervised by the charge nurse to ensure devices are applied on the resident as per plan of care. The Assistant Director also stated they were not aware devices were not being applied. On 11/03/2025 at 2:01 PM, the Medical Director was interviewed and stated they place an order for 'curative devices' recommended for residents, and other devices are at the discretion of the therapist and nurses. The Medical Director also stated it is usually dependent on the Rehabilitation department who makes the recommendation, nursing staff implements the recommendations and documents it in the resident's plan of care to ensure the interventions are carried out. The Medical Director further stated no physician orders is needed for knee and elbow braces as they are just to prevent further contractures and not to cure the contractures. 10 NYCRR 415.12 (e)(2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brooklyn Ctr for Rehab and Residential Health Care

170 Buffalo Avenue Brooklyn, NY 11213

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm

#6 pick Resident #2 up from the floor and put them back to bed, and then they immediately went to notify

the charge nurse. Certified Nursing Assistant #7 also stated Certified Nursing Assistant #6 did not call them to help assist in use of the mechanical lift for the transfer. Certified Nursing Assistant #7 further stated they were suspended for helping to pick up Resident #2.

Residents Affected - Few

On 10/31/2025 at 12:15 PM, Certified Nursing Assistant #6 was interviewed and stated they were transferring Resident #2 from the bed to the recliner chair alone when the Hoyer lift canvas loosened, and Resident #2 fell out to the floor. Certified Nursing Assistant #7 walked in and assisted them in putting Resident #2 back into the bed. Certified Nursing Assistant #6 stated they decided to transfer Resident #2 alone after trying to find someone to help without any success as the other four (4) Certified Nursing Assistants on the unit were busy with their assigned residents and the two (2) nurses were busy giving medications to the residents. Certified Nursing Assistant #6 stated they knew they should call for another staff to help and they tried to look for someone but could not readily get anyone, and they thought Resident #2 had been in bed too long, so they just went ahead and did it alone to ensure Resident #2 was taken out of bed on time.

On 10/31/2025 at 11:26 AM, Licensed Practical Nurse #1 was interviewed and stated they were waiting to assist Certified Nursing Assistant #7 with a resident's shower when Certified Nursing Assistant #7 came to inform them Resident #2 fell when Certified Nursing Assistant #6 was trying to transfer resident from bed by themself with the mechanical lift. Registered Nurse Manager #1 was immediately notified and assessed Resident #2, the doctor was notified and an order for stat x-ray was obtained. Licensed Practical Nurse #1 also stated Certified Nursing Assistant #6 did not call for help before using the mechanical lift to transfer Resident #2 by themself.

On 10/31/2025 at 11:52 AM, Registered Nurse Manager #1 was interviewed and stated they were on the unit on the day of the incident, and they were called to Resident #2's room to assess Resident #2 who reportedly fell during transfer with the mechanical lift. Registered Nurse Manager #1 also stated Resident #2 was already placed back in bed when they got to the resident's room. During assessment, Resident #2 was observed with decreased passive range of motion on the right lower extremity with facial grimacing when gentle passive range of motion was attempted. Registered Nurse Manager #1 stated a stat x-ray was done as per the physician's order and facility protocol. Registered Nurse Manager #1 stated the x-ray results revealed a right hip fracture, and Resident #2 was transferred to the hospital for further evaluation/orthopedic surgery as per the physician's order.On 11/03/2025 at 2:20 PM, the Associate Administrator was interviewed and stated they do not know why these injuries are happening and they should not be happening.

On 11/03/2025 at 3:08 PM, the Medical Doctor, who is also the Medical Director, was interviewed and stated they had a discussion with the Director of Nursing and the Administrator about the incidents of staff not following the plan of care causing accidents. The Medical Director stated the staff was educated, and

the interdisciplinary team has weekly meetings to discuss hospitalizations, and situations that occurred leading to the hospitalization to determine if the Medical Director can assist in any way. The Medical Director further stated the Team meets weekly and discusses falls, weight loss or any high-risk issues. 10 NYCRR 415.12(h)(2)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet