17-06-253 FOIL From NYS Department of Health

DEPARTMENT OF HEALTH AND HUMAN SERVICES AH
CENTERS FOR MEDICARE & MEDICAID SERVICES "A" FORM

STATEMENT OF ISOLATED DEFICIENCIES WHICH CAUSE PROVIDER # MULTIPLE CONSTRUCTION DATE SURVEY
NO HARM WITH ONLY A POTENTIAL FOR MINIMAL HARM A BUILDING: ______________________ COMPLETE:
FOR SNFs AND NFs
AF0354A B WING _____________________________ 9/21/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

570 CONEY ISLAND AVENUE
PARK MANOR ADULT HOME BROOKLYN, NY
ID
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TAG SUMMARY STATEMENT OF DEFICIENCIES
C2434 Continued From Page 3

Based on staff interviews and a review of facility records during the complete inspection conducted on
9/19/11, 9/20/11 and 9/21/11, it was determined that the operator failed to ensure that a record of the facility's
schedule of organized activities was maintained for (6) months, and also failed to ensure that each activities
schedule identified the location of the activity and the provider of each activity, as evidenced by the
following:
- This surveyor requested copies of the activities' schedule on the morning of 9/20/11. Several hours later,
after this surveyor had requested the schedules a second time, Employee #1 reported that they were locked in
the activities' closet, and he could not find the key. Employee #1 stated that the activities director would be
arriving at the facility at 2:30pm, at which time he would provide access to the activities' calendars. Shortly
before the activities' director arrived, Employee #1 provided this surveyor with the calendars from April
2011 to July 2011. At approximately 2:45pm, this surveyor spoke to Employee #4, the activities' director,
who reported that she did not know she was supposed to keep a copy of the calendars, and therefore did not
have a record of the schedule of events for August 2011. Employee #4 stated that the posted calendar
reflected the scheduled events for the current month, September 2011.
- Upon review of the activity calendars, it was determined that the May 2011 calendar did not identify the
location or the provider of each activity. (KE)
C2502 487.8 (a) Food service
(a) The operator shall provide meals which are balanced, nutritious and adequate in amount and content to
meet the daily dietary needs of residents.
This Regulation is not met as evidenced by:

Based on observation, staff interview and record review during a complete inspection on 9/19/11 and
9/21/11, this surveyor determined that the operator failed to ensure that residents were provided with meals
that were adequate in amount and content to meet their daily dietary needs. Specifically:
- During lunch observation on 9/19/11, Employee # 10 and #11 were observed to serve the following
inadequate portion sizes of the planned meal items at lunch : (a) 1-1/2 ozs instead of planned 2ozs of sliced
cheese in the grilled cheese sandwiches; and (b) (3) ozs instead of planned 8ozs of cole slaw. (IL).
C2530 487.8 (d) (1-2) Food service
(d) Menu planning.
(1) Menus for regular and modified diets and snacks are to be planned to furnish sufficient nutrients and
calories to meet the recommended dietary allowances of the Food and Nutrition Board of the National
031099
If continuation sheet 4 of 8
Event ID: GSU311
FOR SNFs AND NFs
AF0354A B WING _____________________________ 9/21/2011

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Academy of Science, National Research Council, adjusted for age, sex and activity.
(2) The following food groups shall be included in each daily menu:
(i) milk--two or more cups served as beverage or used in cooking. Fortified whole, skim or low fat
milk, flavored whole or fortified milk, buttermilk, cheese may be used. Cheese may be used as milk or meat,
but not both;
(ii) meats--two or more servings of meat, fish, poultry, eggs, cheese or other equivalents. Each
serving must provide an edible portion of at least two ounces;
(iii) vegetables and fruits--four or more servings of at least onehalf cup each, citrus fruit or other
fruit and vegetable with vitamin C should be used daily. A dark green or deep yellow vegetable or fruit with
vitamin A should be used at least every other day. Fruit and vegetable juices may be used;
(iv) breads and cereals--four or more servings. Whole grain or enriched breads, cereals, pasta
products may be used. Other foods may be added to the meal to provide personal satisfaction, additional
nutrition and calories.

Based on observation, staff interview and menu review during the complete survey on 09/19/11 and
09/21/11, this surveyor determined that the operator did not ensure that the facility's planned 3-week cycle
menus included (4) or more servings of vegetables and fruits daily as required. Specifically:
- In Cycle (1), on Monday, (2) servings of fruits and vegetables were planned.
- In Cycle (3), on Sunday, (3) servings of fruits and vegetables were planned; and on Saturday, (2) servings
of fruits and vegetables were planned. Also, the type of "Fresh fruit in season" served on Monday (9/5/11)
and Saturday (9/10/11) was not indicated. (IL)
C2710 487.9 (a) (3) Personnel
(3) The operator shall conduct an initial program of orientation and in-service training for employees and
volunteers, which includes:
(i) orientation to the characteristics and needs of the population;

031099
Event ID: GSU311
FOR SNFs AND NFs
AF0354A B WING _____________________________ 9/21/2011

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(ii) discussion of the residents' rights and the facility's rules and regulations for residents;
(iii) discussion of the duties and responsibilities of all staff;
(iv) discussion of the general duties and responsibilities of the individual(s) being trained;
(v) discussion relative to the specific duties and tasks to be performed; and
(vi) training in emergency procedures.

Based on a review of (9) employees' records and staff interviews during the complete inspection on 9/19/11,
9/20/11 and 9/21/11, it was determined that the operator failed to ensure that (1) employee received an initial
program of orientation training as required, as evidenced by the following:
- Employee #4 was hired on 8/11/11. Upon a review of her record, it was determined that an initial program
of orientation training was not provided to this employee. (KE)
C2722 487.9 (a) (4) Personnel
(a) General requirements.
(4) The operator shall conduct ongoing in-service training, and shall provide opportunities for
employees and volunteers to participate in work-related training provided by the operator or others.

Based on a review of the employees' in-service training records from 12/1/10 to 09/21/11(dated 12/1/10,
3/30/11, 6/11/11, and 9/13/11), there was no evidence that any of the facility's Food Service Employees
received required in-service training in appropriate sanitation of the kitchen, and the utensils and equipment
utilized in food preparation and service. (IL)
C2798 487.9 (a) (13) Personnel
(a) General requirements.
(13) Employees who have direct contact with residents shall be able to speak, read and write English,
and speak the predominant language of residents.
031099
Event ID: GSU311
FOR SNFs AND NFs
AF0354A B WING _____________________________ 9/21/2011

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Based on observation and staff interviews during the complete inspection conducted on 9/19/11, 9/20/11 and
9/21/11, it was determined that the operator failed to ensure that (1) employee, who has direct contact with
residents, spoke English, as evidenced by the following:
- On 9/19/11, it was observed by (4) surveyors that Employee #6 could not communicate in English. Also,
on 9/19/11, after a conversation with Employee #6, Employee #1 told (2) surveyors that the elevator was
being used by Employee #6 to transport air conditioners, and therefore could not be used at that time. Later
that day, it was determined that the elevator was actually broken, and that Employee #6 was not able to make
that clear to Employee #1 due to the language barrier. Additionally, on 9/20/11, (2) surveyors observed a
resident trying to explain a maintenance need to Employee #6. However, due to the language barrier,
Employee #6 was not able to understand what the resident was requesting. Upon interview, Employee #2
stated that she usually determined what the residents' maintenance needs were, and passed those needs on to
Employee #6 to ensure that the needs were being addressed. (KE)(JSM)(AI)(IL)
C3508 487.10 (c) (1-3) Records and reports
(c) Resident records.
(1) The operator shall maintain complete, accurate and current records for each resident.
(2) These records shall be maintained in the facility and shall be available for review and inspection by
department staff designees.
(3) Records shall be maintained in a manner which assures resident privacy and accessibility to staff to
use in the provision of routine and emergency services.

Based on observation, staff interviews, a review of facility records, and a review of (14) residents' records,
during the complete inspection conducted on 9/19/11, 9/20/11 and 9/21/11, it was determined that the
operator failed to ensure that accurate records were kept for (1) resident, as evidenced by the following:
- Resident #12's name was documented incorrectly, with the wrong last name, on both the "Park Manor
Special Diet" list and the "Park Manor Adult Home Floor Plan As of 2011." When asked what
the resident's correct last name was, Employee #2 stated that it was the name listed on the census and that she
had made a mistake on the other documents. (KE)
C4162 487.11 (i) (4) (iii-v) Environmental standards
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Event ID: GSU311
FOR SNFs AND NFs
AF0354A B WING _____________________________ 9/21/2011

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(i) Furnishings and equipment.
(4) Each operator shall furnish each resident with the following minimum bedroom equipment:
(iii) a table;
(iv) a lamp;
(v) lockable storage facilities, which cannot be removed at will, for personal articles and
medications;

Based on observations of (20) residents' rooms, all common areas, and all non-resident spaces, during the
complete inspection on 9/19/11, the operator failed to furnish each resident in (1) of those rooms with a
lamp. Specifically:
- Room #B 4 was a double occupancy room and contained only (1) lamp. (AI)
031099
Event ID: GSU311
PRINTED: 04/10/2017
FORM APPROVED
New York State Department of Health
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
PARK MANOR ADULT HOME
BROOKLYN, NY 11218
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
A 734 Continued From page 1 A 734
on a 90-day trial basis. (KE)
CORRECTIVE ACTION REQUIRED:

The operator must:
1) Immediately cease the practice of admitting
trial period or temporary stay residents.
2) Ensure that only those services originally
approved and stipulated by the operating
certificate are provided to residents. Develop,
implement and maintain policies and procedures
to ensure that the facility does not provide
services to residents beyond those the operator
is permitted by law and regulation to provide.
3) Appoint a specific staff person to be
responsible to supervise, monitor and ensure
compliance with the above mentioned
policies/procedures and to prevent future
recurrence.
4) Submit, with the response to this report,
copies of any and all policies and procedures that
have been implemented.
C 662 487.4 (h) Admission standards C 662
(h) Each resident interview shall:
(1) include explanation of the conditions of

residency, including but not limited to the
admission agreement, resident rights and
responsibilities, facility rules and regulations and
the personal allowance protections available to
Supplemental Security Income or HR recipients;
(2) ascertain that the facility program can:
(i) meet the physical needs and personal

care needs of the resident, including dietary
needs occasioned by cultural or religious practice
or preference or medical prescription; and
Office of Primary Care and Health Systems Management
STATE FORM 6899
GSU311 If continuation sheet 2 of 28
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FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
C 662 Continued From page 3 C 662
physical, social, personal care, cultural/religious,

dietary, and psycho-social needs are evaluated,
and a determination is made, prior to the
resident's admission, that the program can meet
those needs.
2) This determination must be based upon a
pre-admission interview with the resident and any
other pertinent sources, and must be
summarized in writing, including the date of the
interview and identification of those present.
3) Conduct in-service training with the
appropriate staff on the completion of the
pre-admission interview summary and the
importance of determining all the residents needs
before admission.
4) Submit copies of the training's agenda and
sign-in sheet. Indicate the name(s) of staff
responsible for ongoing quality assurance and
future compliance in this area of operation.
C1518 487.6 (c) (5) Resident funds and valuables C1518
(c) Personal allowance accounts.
(5) Residents shall have access to personal

allowance accounts at least four hours daily,
Monday through Friday. The access schedule
must be posted and may not be changed without
five days' advance notice.

Based on observation, staff interviews, and a
review of facility records, during the complete
inspection conducted on 9/19/11, 9/20/11 and
9/21/11, it was determined that the operator failed
to provide residents with access to their
facility-maintained personal needs allowance
(PNA) accounts for at least four hours daily,
Monday through Friday, and failed to post an
STATE FORM 6899
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FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
C1518 Continued From page 4 C1518
accurate schedule, as evidenced by the

following:
- There were two notices, regarding PNA access,

posted in the same hallway of the facility. One
read "Banking hours are as follows:
Monday-Friday 9:00am-11:00am and
3:00pm-5:00pm." The other notice read
"Banking hours: 10:00am-12:00pm and
3:00pm-5:00pm." Upon interview, Employee #1
stated that the correct hours should be
10:00am-12:00pm and 3:00pm-5:00pm, but that
he typically provided PNA access all day.
However, on 9/19/11, Employee #1 did not arrive
at the facility until approximately 10:40am, and
was therefore unavailable to provide residents
access to their PNA accounts for (40) minutes of
the posted time. Several residents were
observed looking for someone to conduct
financial transactions during this time period.
Employee #1 and Employee #2 stated that
Employee #1 was the only person with access to
the PNA accounts, and that there was no one
else available, or authorized to provide residents
with access to their PNA accounts. (KE)

- Develop a system which allows residents
access to personal allowance accounts at least
four hours daily, Monday through Friday, and
post the actual schedule of access.
- Ensure that funds are available for distribution

and individual PNA records are available for
resident review during the posted hours.
- Provide in-service training to all appropriate

staff involved in the disbursal of personal
allowance funds to ensure that they are aware of,
STATE FORM 6899
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FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
and compliant with, the requirements regarding

access.
- Submit, along with the response to this report, a

copy of the posted schedule of access, the title(s)
of the staff assigned to maintain residents'
accounts, and a copy of the in-service training,
including the agenda, the date(s) and signatures
of the staff in attendance.
C2370 487.7 (g) (3) Resident services C2370
(g) Case management.
(3) The operator shall establish a system of

recordkeeping which documents the case
management needs of each resident and records
case management activities undertaken to meet
those needs.

Based on observation, staff interviews, a review
of facility records and a review of (14) residents'
records, during the complete inspection
conducted on 9/19/11, 9/21/11 and 9/22/11, it
was determined that the operator did not ensure
that ongoing case management records were
complete for (4) residents, as evidenced by the
following:
- Upon interview, Employee #7 stated that

Resident #26 did not allow staff into her room to
clean and that Resident #26 often yelled at the
housekeeping staff. Based on observation,
Resident #26's room was cluttered.
After reviewing the case management notes for
Resident #26, it was determined that there were
no case management notes addressing the
STATE FORM 6899
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FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
to ensure a system of documentation of all

resident case management needs and services.
If established policies are not in compliance with
regulations, revise policies as necessary.
In-service staff on any policy and procedures for
case management documentation. Submit, with
the response to this report, copies of any new
policies, and documentation of training content
and attendance.
- Develop or review and revise a monitoring
system through the facility's quality assurance
program to ensure continual compliance with
department regulation including identification of
non-compliance and immediate corrective action.
C2510 487.8 (c) Food service C2510
(c) Information on each resident's prescribed

dietary regimen and food allergies shall be
available in the food service area and shall be
used in the planning, preparation and service of
resident meals and snacks.

Based on observation, staff interview and record
review during a complete survey on 9/21/11, this
surveyor observed that the prescribed dietary
regimen of (25) diabetic residents, as indicated
on the diet roster, were not being used in the
planning, preparation and service of meals and
snacks as required. Specifically
- During Lunch observation on 9/21/11, every

resident, including the (25) diabetic residents,
was served regular strawberry jello and a
"Pre-sweetened soft drink mix Fruit Punch" (the
first ingredient listed for this fruit punch was
Dextrose).
STATE FORM 6899
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FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
- One month's food requisition orders were

reviewed, and there was no evidence that the
diet alternate of this punch and jello was ordered
in accordance with the planned menus. - -- -
Employee #10 was interviewed and she stated
that the regular strawberry jello and
pre-sweetened fruit punch were the only types of
these food products available to be served to
residents. (Previously cited 11/23/10 & 6/17/11)
(IL)(AXD)(IL)

The operator must ensure that each resident's
diet order in the food service area is used for
food preparation and service, and that the
menus, as well as, residents' dietary orders, are
utilized in the requisition and preparation of
foods.
C2610 487.8 (e) (1) Food service C2610
(e) Food purchasing, storage and preparation

and service.
(1) The operator shall comply with

regulations relating to food service for sanitation,
safety and health, as set forth by the New York
State Sanitary Code (10 NYCRR Part 14) and
other applicable county and local health codes.

Based on observation and record review during a
complete survey on 9/19/11 and 9/21/11, the
operator was not in compliance with regulations
relating to food service for sanitation, safety and
health as set forth by the New York State
Sanitary Code (10 NYCRR Part 14) and other
applicable county and local codes. Specifically:
STATE FORM 6899
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FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
IN THE KITCHEN:
1) There were multiple flies on the food
preparation table, on the (hanging) clean utensils
and on the pots and pans.
2) The can opener had peeling and rusty areas
with dark dirty accumulations on the blade.
3) There was a wide unprotected open area
between the top of the door that opened to the
backyard and the ceiling.
4) There was an accumulation of dried dirty
leaves between the glass door that opened to the
backyard.
5) There were multiple holes and stains in the
ceiling over the food preparation table and next
to the kitchen hood.
6) There were dirt accumulations along the wall
between the food preparation table and the spice
refrigerator.
7) There were dirty crumbs accumulated in the
clean utensils drawer. The green head of a
serving spoon had dark crusty dirt.
IN THE DINING ROOM:

8) Multiple flies were perched on the residents'
cups and utensils on the tables.
9) There were multiple torn and sticky plastic
table cloths.
10) The coffee cups placed on the tables were
also dirty and sticky.
11) There was an open roach bait with dead
roaches on the floor in the corner underneath the
air-conditioner next to a resident's chair.
12) The right side window screen was open and
not properly sealed, and the left side screen was
torn.
13) There was a hole in the wall next to the
air-conditioner's electrical outlet.
14) There were (2) stained ceiling tiles, and
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A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
multiple peeling and torn wall paper.

15) There multiple torn chair seats and dirty
chairs with food crumbs in the crevices.
16) There were dark dirt accumulations along the
wall crevices underneath the window.
IN THE FOOD STORAGE AREA:

17) There were multiple dented cans on the
shelves in the storeroom: marinara sauce,
tomato sauce, sauerkraut and sliced peaches.
This surveyor observed a dented can of peaches
opened by Employee #10 to be served to the
residents, but intervened and it was discarded.
- During dishwashing observation on 9/19/11,

Employee #10 was unable to demonstrate that
the dishwasher was effectively sanitizing the
residents' dishes and utensils. The wash cycle
temperature gauge remained at (0) degree
Fahrenheit instead of (150-160) degrees as
recommended; while the sanitizing cycle
temperature gauge was initially at a constant
(195) degrees Fahrenheit, but dropped to
between (178 to 181) degrees Fahrenheit after
(4) wash cycle attempts. The recommended final
rinse temperature indicated on the machine was
(180 -195) degrees Fahrenheit. Both gauges
appeared to be broken. When interviewed, the
employee stated that when steam comes out of
the dishwashing machine and the machine is hot,
she knows that the dishes, pots and pans are
clean and sanitized. When asked about the
function of the temperature gauges, she stated
that it should be (160) degrees Fahrenheit and
that it should move from left to right, "I don't
know". She said that the wash gauge was not
functioning.
- On 9/21/11, Employee #1 and #10 stated that
the electronic booster was broken and a "manual
STATE FORM 6899
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A. BUILDING: ______________________
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09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
method" was being used. However, both

employees were unable to explain to the
surveyor the procedure for the manual method.
No written or posted instructions were presented
to this surveyor. The wash gauge was still at (0)
degree Fahrenheit during wash cycles and the
final rinse gauge was still starting out at 195
degrees Fahrenheit then decreasing to between
178-180 degrees Fahrenheit when the cycle
changed to final rinse.
This surveyor took the temperature of the final
rinse water in a cup inside the dishwasher,
immediately after the machine cycle was
completed, with a manual thermometer, and the
water temperature registered (143) degrees
Fahrenheit.
- On 9/21/11, Employee#11 was observed and

interviewed on the facility's procedure for
sanitization of pots/pans. She washed and rinsed
the pots and pans in soapy and clean water in
the two respective sinks next to the stove/oven;
then she took the utensils over to a 3rd sink,
across the kitchen next to the dishwasher, and
rinsed them again in an unmeasured ratio of
bleach-to-water mixture.
- There was no evidence that Employee #10 and

#11 had received any in-service training that
addressed the proper procedures for the
sanitation of dishes, pots and pans using the
available equipment in this facility. (Previously
cited 11/23/10 & 6/17/11)(IL)(AXD)(IL)

The operator must develop, implement and
maintain policies and procedures, including
quality assurance procedures, and provide
in-service education to all food service
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FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
employees, regarding proper cleaning and

sanitizing of kitchen equipment in accordance
with the State Sanitary Code Subpart 14-1.
The operator must also increase supervisory
oversight to ensure that the developed policies
and procedures are being followed.
The operator must ensure that kitchen equipment
are maintained and functioning according to the
manufacturers' specifications.
Include in the response to this report, a copy of
the specific in-service training with lesson plans
and attendance records.
Submit, with the response to this report, a copy
of the policies and procedures, and appropriate
cleaning and maintenance schedules.
C2614 487.8 (e) (3) Food service C2614
(e) Food purchasing, storage and preparation

and service.
(3) Food purchases and preparation shall be

based on:
(i) planned menus;
(ii) tested quantity recipes, adjusted to

yield the required number of servings; and
(iii) the estimated number of meals to be

served.

Based on a review of food service records during
the complete survey on 9/19/11 and 9/21/11, this
surveyor observed that the operator did not have
tested quantity recipes, adjusted to yield the
required number of servings for all of the planned
meal items in the 3-week cycle menus; and that
STATE FORM 6899
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AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
the recipes were not followed during meal

preparation, as evidenced by the following:
- The facility's recipes were reviewed, and it was

determined that there were no recipes available
for the following planned meal items: Breaded
fish and Asian chicken salad plate.
- During meal preparation observation on

9/19/11: 1) cole slaw was prepared with milk and
mayonnaise that was not part of the required
ingredients, and 'celery seeds' was not used as
an ingredient as planned; b) Macaroni salad was
prepared without hard boiled eggs and green bell
pepper as indicated in the recipe; however,
onions and red peppers were used, which were
not part of the planned ingredients.
- On 9/21/11, Employee #10 prepared fruit punch

by using (1) 8.6 ozs sachet of the punch to an
unmeasured amount of water in a metal
container. The sachet indicated that the sachet's
contents should be mixed with (2) gallons of
water. (IL)

The operator must develop, implement and
maintain policies and procedures to ensure that
tested quantity recipes are used for the
preparation of all of the meals in the planned
menus.
The operator must provide in-service training to
appropriate food service staff on the need to
prepare and serve the planned meals according
to the ingredients identified on the recipe.
Supervision must be provided to ensure that the
cooks/aides are preparing the meals according to
the respective recipes.
Submit the in-service training lesson plan and
STATE FORM 6899
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09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
attendance records with the plan of correction.
C3094 487.9 (c) (15,17-18) Personnel C3094
(c) Administration.
(15) An administrator shall participate in a

program of continuing education which shall:
(i) consist of a minimum of 60 clock

hours over a two-year period;
(ii) require the prior approval of the

department;
(iii) include courses, workshops,

educational seminars, conferences or
college-level programs which are directly related
to the fields of administration, supervision,
program planning and services, human behavior,
geriatrics, care of the mentally and physically
disabled, social work, health care, financial
management or nutrition; and
(iv) include, for the administrator of a

facility with a significant number of mentally
disabled residents, at least 15 hours of
programming related to the care and treatment of
the mentally disabled.
(17) If an administrator has a

post-baccalaureate degree in an approved
course of study, a minimum of 30 clock hours for
each two-year period shall be accepted for the
three two-year cycles following award of the
degree.
(18) Continuing education courses approved

by the department and attended by the case
STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
manager or activities director shall be accepted

for a maximum of 20 of the 60 clock hours
required.

Based on staff interviews and record review
during a complete inspection on 9/19/11, 9/20/11
and 9/21/11, it was determined that the operator
failed to ensure that the facility's administrator
participated in a program of continuing education
consisting of a minimum of (60) clock hours over
each two-year period as required, as evidenced
by the following:
- This surveyor asked Employee #1 for a record

of his continuing education credits on 9/20/11.
Several hours later, Employee #1 provided this
surveyor with continuing education credits, none
of which were received during the previous
two-year period. Employee #1 stated that he
would look for his recent credits. However, this
surveyor was never provided any record of
continuing education credits completed within the
past two years. (KE)

The operator must:
- Ensure that the administrator participates in 60
hours of continuing education courses approved
by the department for each two year period.
- Submit to the Department, with the response to
this report, a plan for the administrator and/or
case manager to obtain a minimum of 30 hours
of continuing education credits in the next year.
C4106 487.11 (h) (16) Environmental standards C4106
(h) Safety procedures.

STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
(16) A hallway or corridor shall not be used

for storage.

During the complete inspection on 09/19/11, this
surveyor determined through observation, that
the operator failed to ensure that hallways were
not used for storage. Specifically:
- During the walk through of the facility it was

noted that the operator stored bed frames, box
springs, mattresses and ceiling tiles in the third
and second floor hallways. (AI)

Remove the above mentioned items from the
hallway and submit documentation to this office.
In-service staff on not using hallways for storage
and submit documentation including date,
agenda and staff attendance to this office.
C4246 487.11 (i) (11-12) Environmental standards C4246
(i) Furnishings and equipment.
(11) All windows in resident-occupied areas

shall be equipped with curtains, shades or blinds.
(12) All operable windows shall be equipped

with screens.

Based on observation of (20) residents' rooms,
and all common areas and non-resident spaces,
during a complete inspection on 09/19/11, the
operator did not ensure that the windows in (4)
STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
residents' rooms were equipped with curtains,

shades or blinds that were in good condition.
Specifically:
- Room #B 3 contained (1) missing blind.

- Room #B 6 contained (2) missing blinds.
- Room #B 2 contained (1) missing blind.
- Room #C 1 contained (1) torn blind. (AI)

The operator must replace the damaged or
missing blinds, and must also replace all
damaged or missing window screens in all of the
above identified residents' rooms and must
provide documentation to the department that
this has been done.
The operator must ensure that windows in all
residents' rooms are clean, and are provided with
curtains, shades or blinds, as well as, screens
that are in good repair.
The operator must establish a quality assurance
plan to ensure continued compliance. A copy of
the operator's quality assurance plan must be
submitted with this report.
C4276 487.11 (j) (1-3) Environmental standards C4276
(j) Housekeeping.
(1) The operator shall maintain a clean and

comfortable environment.
(2) All areas of the facility shall be free of

vermin and rodents.
(3) All areas of the facility, including but not

limited to the floors, walls, windows, doors,
ceilings, fixtures, equipment and furnishings,
shall be clean and free of odors.
STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
the continued maintenance of the facility.
(2) The building and grounds shall be

maintained in a clean, orderly condition and in
good repair.
(3) All equipment and furnishings shall be

maintained in a clean, orderly condition and in
good working order.

Based on observations, staff interviews and a
review of facility records, during the complete
inspection on 09/19/11, including a sample of 20
residents' rooms, all common areas and all
non-resident spaces, the operator did not ensure
that equipment and furnishings in (3) residents'
rooms, and one communal area (the elevator)
were maintained as required, as evidenced by
the following:
- Room #C 9 contained a broken chest of

drawers.
- Room #B 11 contained a broken chest of
drawers (door).
- Room #C 8 contained an entrance door with no
door knob.
- The elevator was broken throughout the period
of the survey. On interview, the operator stated
that the maintenance crew was using the
elevator to move A/C units to the basement, but
on investigation it was noted that the elevator car
was stuck on the basement level. (AI)

The operator must immediately repair
above-cited deficiencies, and must ensure that all
equipment and furnishings are maintained daily
STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
and as frequently as required. Additionally, the

operator must develop, implement, and maintain
a quality assurance system of maintenance that
includes schedules for the prompt repairs of all
rooms, bathrooms and equipment. Maintenance
staff must be in-serviced regarding maintaining
areas of the facility as promptly as needed.
Submit documentation to this office, including a
copy of the in-service agenda, a signed/dated list
of attendees, and the name(s) of designated staff
responsible for continuing compliance in this
area.
C4312 487.11 (k) (5) Environmental standards C4312
(k) Maintenance.
(5) Floors and floor coverings shall be free of

cracks and missing or raised portions.

Based on inspection of (20) residents' rooms and
all common areas of the facility during the
complete inspection on 09/19/11, the surveyor
determined that the operator failed to ensure that
the floors and floor coverings were free of cracks
in (4) residents' rooms and (1) common area.
Specifically:
- Room #C10 contained (6 ) cracked floor tiles.

- Room #B5 contained (4) cracked floor tiles.
- Room #B8 contained (8 ) cracked floor tiles.
- Room #A4 contained (4 ) cracked floor tiles.
- The lobby area contained (10) cracked floor
tiles.
(Previous finding 6/17/11)(AI)

The Operator must ensure that all damaged floor
STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
mattresses, box springs and bed frames from

residents' rooms. Submit the receipts for the
purchase of new beds and mattresses and
documentation from the extermination company
with the response to this report. Include the date
and time when the above listed rooms, and all
other necessary rooms, were professionally
treated for bedbugs by a licensed exterminator.
Ensure that a plan is developed to refer
residents, whose rooms are infested, to their
primary physicians to evaluate them for bedbug
bites or necessary follow up regarding conditions
associated with a bedbug infestation. A record of
all residents found to have bedbug bites,
including the results of physician's evaluations,
must be kept on-site and available for review by
department staff.
Provide periodic in-service training regarding the
prevention and elimination of bed bugs to
housekeeping and other facility staff as
appropriate.
Encourage residents to report observations of
bed bugs to facility staff .
Maintain a log to record both resident complaints
and observations by staff including the rooms or
areas noted to have bedbugs throughout the
facility.
C4334 487.11 (k) (15) Environmental standards C4334
(k) Maintenance.
(15) To ensure safe, proper operating

conditions, the following systems and equipment
must be inspected or tested by a service
company at least once every 12 months, or more
frequently if required by local codes:
(i) smoke detection systems;

STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
(ii) fire alarm system;
(iii) sprinkler system;
(iv) fire extinguishers;
(v) heating system;
(vi) elevators;
(vii) water supply, if other than a

municipal system.

During the complete inspection conducted on
09/19/11, this surveyor determined through
record review and interview with facility staff, that
the operator failed to ensure that the facility's
Sprinkler system was inspected by a service
company at least once every (12) months as
required. Specifically:
- During the review of facility records, the

operator failed to provide a current inspection
certificate for the sprinkler system, to verify that it
was being maintained as required. (AI)

The operator must immediately arrange for the
inspection and certification of the above
mentioned equipment by an authorized service
company and submit documentation to this office.
C4460 487.11 (l) (14) (v-x) Environmental standards C4460
(l) Space requirements for adult homes.
(14) Bedrooms.
STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
(v) In a facility certified after September

22, 1978, bedrooms shall be limited to single or
double occupancy.
(vi) Single bedrooms shall have a

minimum floor area of 100 square feet, exclusive
of foyer, wardrobe, closets, lockers and toilet
rooms.
(vii) Double bedrooms shall have a

minimum floor area of 160 square feet, exclusive
of foyer, wardrobe, closets, lockers and toilet
rooms.
(viii) Notwithstanding subparagraph (vi)

of this paragraph, any single bedroom in use and
approved by the department or the board of
social welfare as of September 22, 1978 which:
(a) provides a minimum of 85 square

feet, exclusive of entrance way and closet space,
and is equipped as required by paragraph (i)(4)
of this section, may continue to be used;
(b) has less than 85 square feet,

exclusive of entrance way and closet space, shall
no longer be used as a bedroom after a change
of operator occurs.
(ix) Notwithstanding subparagraph (vii) of

this paragraph, any double bedroom in use and
social welfare as of September 22, 1978 which:
(a) provides a minimum of 70 square

feet per resident exclusive of entrance way and
closet, provides a minimum of 3 feet between
beds and is equipped as required by paragraph
STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
(i)(4) of this section may continue to be used;
(b) has less than 70 square feet per

resident, exclusive of entrance way and closet
space, shall no longer be used as a double
bedroom after a change of operator occurs.
(x) Not more than two residents shall

share a bedroom; however, if a bedroom was
used for more than two residents as of
September 22, 1978, and such use was
social welfare, such bedroom may continue to be
used under the conditions set forth in
subparagraph (ix) of this paragraph.

Based on observation of (25) residents' rooms
and record review, during a complete survey
conducted on 09/19/11, the surveyor determined
that the Operator failed to ensure that (25)
residents' bedrooms contained a minimum of (70)
square feet per resident, exclusive of entrance
way and closet space, and a minimum of (3) feet
between beds, as evidenced by the following:
1) The following (11) resident bedrooms each

contained (3) residents, and none were a
minimum of 210 square feet (i.e. 70 square feet
per resident):
Room A1 measured 135.02 square feet;
Room B1 measured 141 square feet;
Room B2 measured 148.42 square feet.;
Room B5 measured 149.38 square feet;
Room C1 measured 144.86 square feet;
STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)

Room C8 measured 162.86 square feet.
2) The following (11) resident bedrooms each

contained (2) residents, and none were a
minimum of 140 square feet (i.e. 70 square feet
per resident):
Room A4 measured 132.62 square feet;
Room A3 measured 139.24 square feet.
3) The following (2) resident rooms with 3 beds

each did not have a minimum of (3) feet between
each bed:
- Room B2: the space between the side and
head of (2) of the beds measured only (1) foot
and (6) inches.
- Room C7: the space between the side and
head of (2) of the beds measured only (2) feet
and (9) inches.
4) Room C6, a (2) bed resident room, did not

have a minimum of (3) feet between each bed.
The space between the sides of the (2) beds
measured only (2) feet and (10) inches.
The operator has consistently failed to provide

the Department with architectural plans (as
promised) for the renovation of the facility's plant,
with the objective of correcting the space
STATE FORM 6899
PRINTED: 04/10/2017
FORM APPROVED
A. BUILDING: ______________________
AF0354A B. WING _____________________________

09/21/2011
BROOKLYN, NY 11218
DEFICIENCY)
deficiencies mentioned above.

(Previously cited 01/18/08, 07/15/08, 01/14/09,
05/28/09, 11/25/09, 3/18/10, 11/23/10 and
06/17/11) (MP) (GD, JSM) (AI) (AXD) (AI) (AXD)
(AI) (AXD)(AI)

For those rooms that do not meet the
requirements previously stated, the Operator
must reduce the census accordingly to ensure
that each resident is provided with a minimum of
70 square feet (exclusive of entrance way and
closet space). Although these conditions may
have existed prior to 09/22/79 , they do not meet
the conditions that would allow for continued use,
specifically as outlined in 487.11(l)(14)(ix)(a)(b)
and in 487.11(l)(14)(i)(4).
The Operator must rearrange rooms to ensure

that a minimum of (3) feet is maintained between
each bed in the aforementioned resident rooms,
and inspect all other resident rooms to ensure a
minimum of (3) feet is maintained between each
bed.
Submit, with the notice of correction/plan of

correction, documentation/evidence that the
resident census has been reduced accordingly,
and that the aforementioned rooms maintain a
minimum of (3) feet is maintained between each
bed.

STATE FORM 6899
Printed: 06/30/2017 2:33:19PM Intake ID:
Due Date: 04/18/2013 Facility ID: AF0354A / ACH
Priority: Non-IJ Medium Provider Number:

Mgmt.Unit: 5NYC
ACTS Complaint/Incident Investigation Report

Letters: Notification:
Created Description
Date Type Party Method
01/18/2013 B601 ACKNOWL TO COMPLAINANT FROM Central Office Written
01/18/2013 Acknowledgement to Complainant
CCIU/Complainant
07/01/2013 B000 NO FINDINGS NO VIOLATIONS/Facility
PROPOSED ACTIONS
Proposed Action Proposed Date Imposed Date Type
State Only Actions 0 Federal
Other 07/01/2013 07/01/2013 State
Closed: 07/01/2013 Reason: Paperwork Complete

END OF COMPLAINT INVESTIGATION INFORMATION
Invest.rpt 01/04 Page 3 of 3

Priority: Non-IJ High Provider Number:

Mgmt.Unit: 5NYC

Created Description
CCIU/Complainant
PROPOSED ACTIONS
State Only Actions 04/04/2017 Federal
Other 04/0 017 State
Closed: 03/31/2017 Reason: No Jurisdiction



Mgmt.Unit: 5NYC

. two residents in the
. residents and in the facility.
Findings Text: Unlicesned Facility closed on 3/31/17. No further action necessary (RTS)
Category: Dietary Services

Subcategory: Menus, Planning, Purchasing
Seriousness:
Findings: Unsubstantiated:Lack of sufficient evidence

Details: It is alleged that the operator has failed to meet the minimum standard of meal preparation: as evidenced by:
. very small meal portions served to residents, and second helpings are denied.
. no lunch served to residents M-F.
Category: Physical Environment

Subcategory: Bed Bugs
Seriousness:

Details: It is alleged that the operator has failed to provide a clean and comfortable living environment free from bed

Subcategory: Maintenance and Safety
Seriousness:

Details: It is alleged that the operator has failed to meet the minimum standard of maintaining the property of this facility
in good working order; as evidenced by:
. a faulty elevator.
. a broken lock on the front door.
. discolored ceilings.
. stained and torn carpeting.
Category: Quality of Care/Treatment

Subcategory Supervision--All Other Areas
Seriousness:

Details: It is alleged that the operator has failed to provide adequate supervision; as evidenced by:
. neighbors being able to walk into the building at all hours of the day and night because the lock on the front
door is broken.
. failing to intervene with residents who are drinking alcohol and smoking marijuana.


Mgmt.Unit: 5NYC

Created Description
CCIU/Complainant
PROPOSED ACTIONS
State Only Actions 04/04/2017 Federal
Other 04/04/2017 State


Priority: Non-IJ Medium Provider Number:

Mgmt.Unit: 5NYC

Seriousness:

Details: It is alleged that there is no hot water on the second and third floors.

Subcategory: Bed Bugs
Seriousness:

Details: It is alleged that the operator has failed to provide a clean and comfortable environment as evidenced by bed
bugs.

Serio

Details: It is alleged that the operator has failed to provide a clean and comfortable environment as evidenced by mice.

Subcategory: Furnishings/Equipment/Room Space
Seriousness:

Details: It is alleged that the operator has failed to provide a clean and comfortable environment as evidenced by
furnishing that are ripped and need to be replaced.
SURVEY INFORMATION
Event ID Start Date Exit Date Team Members Staff ID
V1ET11 03/31/17 03/31/17 Schawelson, Robert T 17949
Intakes Investigated: (Received: 02/15/2017); (Received: 03/17/2014); (Received: 04/15/2014);

(Received: 11/26/2014); (Received: 02/09/2015); (Received: 02/23/2015);
(Received: 06/09/2016)
SUMMARY OF CITATIONS:
Event ID Exit Date Tag
V1ET11 03/31/2017
State - Not Related to any Intakes
C9999-Closing Comments
EMTALA INFORMATION - No Data

Priority: IJ Provider Number:

Mgmt.Unit: 5NYC


Priority: IJ Provider Number:

Mgmt.Unit: 5NYC

Findings Text: The facility was directed to close. Operating Certificate revoked (RTS)
Category: Quality of Care/Treatment

Subcategory: Medication Management
Seriousness:

Details: It is alleged that the facility staff is not giving a resident a prescribed medication for unknown reasons for at least
1 week.
Category: Resident/Patient/Client Rights

Subcategory: Resident Rights
Seriousness:

Details: It is alleged that a resident is not receiving her mail in the facility.
It is also alleged that facility stafff are not treating a resident with courteous, fair, and respectful care and
treatment as evidenced by:
staff refusing her meds
--refusing to look into why a resident's me are not available
--threatening to report a resident for questioning the medication process
--a administrator/owner laughing and screaming at a resident when she has tried to place complaints in the past.
SURVEY INFORMATION
Event ID Start Date Exit Date Team Members Staff ID
V1ET11 03/31/17 03/31/17 Schawelson, Robert T 17949
Intakes Investigated: (Received: 02/15/2017); (Received: 03/17/2014); (Received: 04/15/2014);

(Received: 06/09/2016)
SUMMARY OF CITATIONS:
Event ID Exit Date Tag
V1ET11 03/31/2017
State - Not Related to any Intakes
C9999-Closing Comments
EMTALA INFORMATION - No Data
ACTIVITIES
Type Assigned Due Completed Responsible Staff Member
Schedule Onsite Visit 03/31/2017 03/31/2017 03/31/2017 SCHAWELSON, ROBERT T.
INVESTIGATIVE NOTES
CONTACTS - No Data
AGENCY REFERRAL - No Data
LINKED COMPLAINTS - No Data

17-06-253 FOIL From NYS Department of Health

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DEPARTMENT OF HEALTH AND HUMAN SERVICES AH

CENTERS FOR MEDICARE & MEDICAID SERVICES "A" FORM

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

C2434 Continued From Page 3

C2502 487.8 (a) Food service

This Regulation is not met as evidenced by:

C2530 487.8 (d) (1-2) Food service

(d) Menu planning.

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

C2530 Continued From Page 4

This Regulation is not met as evidenced by:

C2710 487.9 (a) (3) Personnel

(i) orientation to the characteristics and needs of the population;

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

C2710 Continued From Page 5

(iii) discussion of the duties and responsibilities of all staff;

(vi) training in emergency procedures.

This Regulation is not met as evidenced by:

C2722 487.9 (a) (4) Personnel

(a) General requirements.

This Regulation is not met as evidenced by:

C2798 487.9 (a) (13) Personnel

(a) General requirements.

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

C2798 Continued From Page 6

C3508 487.10 (c) (1-3) Records and reports

(c) Resident records.

This Regulation is not met as evidenced by:

C4162 487.11 (i) (4) (iii-v) Environmental standards

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

C4162 Continued From Page 7

This Regulation is not met as evidenced by:

AF0354A B. WING _____________________________

A 734 Continued From page 1 A 734

on a 90-day trial basis. (KE)

CORRECTIVE ACTION REQUIRED:

C 662 487.4 (h) Admission standards C 662

(h) Each resident interview shall:

(1) include explanation of the conditions of

(2) ascertain that the facility program can:

(i) meet the physical needs and personal

AF0354A B. WING _____________________________

C 662 Continued From page 3 C 662

physical, social, personal care, cultural/religious,

C1518 487.6 (c) (5) Resident funds and valuables C1518

(c) Personal allowance accounts.

(5) Residents shall have access to personal

This Regulation is not met as evidenced by:

AF0354A B. WING _____________________________

C1518 Continued From page 4 C1518

accurate schedule, as evidenced by the

- There were two notices, regarding PNA access,

CORRECTIVE ACTION REQUIRED:

- Ensure that funds are available for distribution

- Provide in-service training to all appropriate

AF0354A B. WING _____________________________

C1518 Continued From page 5 C1518

and compliant with, the requirements regarding

- Submit, along with the response to this report, a

C2370 487.7 (g) (3) Resident services C2370

(g) Case management.

(3) The operator shall establish a system of

This Regulation is not met as evidenced by: