Inspection Reports for
Bushwick Center for Rehabilitation and Health Care
50 Sheffield Avenue, Brooklyn, NY, 11207
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
112% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Jun 24, 2025
Visit Reason
Inspection revealed 8 standard health citations and 7 life safety code citations, mostly level 2 severity, with deficiencies in care planning, assessments, infection control, and multiple life safety code issues. All standard health deficiencies were corrected by July 31, 2025.
Findings
Inspection revealed 8 standard health citations and 7 life safety code citations, mostly level 2 severity, with deficiencies in care planning, assessments, infection control, and multiple life safety code issues. All standard health deficiencies were corrected by July 31, 2025.
Deficiencies (13)
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 6, 2025
Visit Reason
The visit was an abbreviated survey conducted to assess compliance with regulations, specifically focusing on the facility's reporting and investigation of an alleged abuse or neglect incident involving a resident fall.
Findings
The facility failed to timely report an alleged abuse involving a resident fall and injury, and did not investigate the fall incident. Resident #5 was found unresponsive on the floor with a hematoma and later pronounced deceased. The fall and injury were not reported to the facility administrator, Director of Nursing, or the New York State Department of Health.
Deficiencies (2)
F 0609: The facility did not ensure timely reporting of suspected abuse, neglect, or theft, including injuries of unknown source, to proper authorities. Resident #5's fall and injury were not reported to the Administrator or State Survey Agency within required timeframes.
F 0610: The facility failed to investigate a fall accident that resulted in injuries. Resident #5 was found unresponsive with a hematoma, but the fall was not investigated to rule out care plan violations.
Report Facts
Residents reviewed for falls: 7
Residents affected: 1
Time resident found unresponsive: 1030
Time resident pronounced deceased: 1116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Did not report Resident #5's fall and injury to Administrator or Director of Nursing and did not initiate investigation | |
| Licensed Practical Nurse #1 | Observed Resident #5 lying unresponsive on the floor | |
| Director of Nursing | Was not notified of Resident #5's fall and injury | |
| Administrator | Was not aware of Resident #5's fall and injury |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jun 6, 2025
Visit Reason
Inspection found 2 standard health citations related to investigation and reporting of alleged violations, both level 2 severity and corrected by July 7, 2025.
Findings
Inspection found 2 standard health citations related to investigation and reporting of alleged violations, both level 2 severity and corrected by July 7, 2025.
Deficiencies (2)
Inspection Report
Renewal
Deficiencies: 1
Date: Aug 7, 2023
Visit Reason
The inspection was conducted as part of a Recertification and Complaint Survey from 07/31/2023 through 08/07/2023 to assess compliance with regulatory requirements and resident care standards.
Findings
The facility failed to ensure residents' right to a safe, clean, comfortable, and homelike environment, with multiple units observed to have damaged furniture, missing closet doors, peeling paint, stained and torn equipment, and maintenance issues such as ceiling damage and loose fixtures.
Deficiencies (1)
F 0584: The facility did not maintain a safe, clean, and homelike environment. Observations included missing closet doors, broken furniture, stained mattress covers, torn and stained equipment, peeling paint, and damaged walls across multiple units.
Report Facts
Units with deficiencies: 4
Survey period: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Interviewed regarding missing closet doors and cleaning practices | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about shower chair cleaning and closet door removal | |
| Housekeeper #1 | Interviewed about cleaning responsibilities for floors and shower rooms | |
| Acting Housekeeping Director | Interviewed about housekeeping rounds and cleaning of equipment | |
| Director of Maintenance (DOM) | Interviewed about furniture maintenance, ceiling leak, and painting schedules | |
| Director of Nursing (DON) | Interviewed about care planning for resident behaviors and cleaning protocols | |
| Licensed Practical Nurse (LPN) #7 | Interviewed about chairs in disrepair at the nursing station | |
| Maintenance Worker (MW) | Interviewed about maintenance and painting activities |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Aug 7, 2023
Visit Reason
Inspection identified 11 standard health citations and 4 life safety code citations, mostly level 2 severity, involving care planning, food safety, accident hazards, privacy, environment, and life safety systems. All deficiencies were corrected by September 18, 2023.
Findings
Inspection identified 11 standard health citations and 4 life safety code citations, mostly level 2 severity, involving care planning, food safety, accident hazards, privacy, environment, and life safety systems. All deficiencies were corrected by September 18, 2023.
Deficiencies (15)
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Aug 7, 2023
Visit Reason
The inspection was a recertification survey conducted from 07/31/2023 to 08/07/2023 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident privacy violations, environmental maintenance issues, incomplete and untimely care plan development and review, unsafe medication administration practices, inadequate supervision of smoking residents, poor personal hygiene care, expired medications storage, food safety violations, and ineffective pest control.
Deficiencies (10)
F 0583: The facility failed to maintain residents' privacy and confidentiality during medication administration and handling of medical information, exposing personal data and residents in public view.
F 0584: The facility did not ensure a safe, clean, and homelike environment; multiple units had missing closet doors, broken furniture, peeling paint, stained and torn equipment, and ceiling damage.
F 0656: The facility failed to develop and implement a person-centered care plan with measurable goals and timetables for a resident who smoked.
F 0657: The facility did not review or revise comprehensive care plans after assessments for two residents with complex medical conditions.
F 0658: The facility failed to ensure professional standards of practice for feeding tube medication administration by not checking tube placement and residuals before medication delivery.
F 0677: The facility did not provide adequate assistance for a resident's grooming needs, resulting in unkempt, matted hair without documented refusal of care.
F 0689: The facility failed to adequately supervise residents to prevent smoking accidents; multiple residents were observed smoking unsupervised outside designated areas.
F 0761: The facility did not ensure medications and biologicals were stored and handled according to professional standards, including expired medications and unattended medication blister packs.
F 0812: The facility failed to ensure food was prepared in accordance with professional food safety standards; staff were observed not performing proper hand hygiene during food preparation.
F 0925: The facility did not maintain an effective pest control program; flies and insects were observed in multiple units and common areas throughout the facility.
Report Facts
Residents sampled: 38
Units inspected: 6
Expired pneumovax vaccine vials: 3
Expired medications: 2
Medication blister packs left unattended: 3
Residents observed smoking unsupervised: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed leaving medications unattended and improper medication administration |
| RN #1 | Registered Nurse Unit Manager | Responsible for medication cart rounds and nurse supervision |
| LPN #3 | Licensed Practical Nurse | Observed leaving resident room door open during medication administration |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy, medication, and care plan deficiencies |
| LPN #7 | Licensed Practical Nurse | Observed expired medications in medication room and interviewed about medication checks |
| Registered Nurse Supervisor #4 | Registered Nurse Supervisor | Interviewed about medication room checks |
| Director of Maintenance | Director of Maintenance | Interviewed about environmental maintenance and pest control |
| Administrator | Facility Administrator | Interviewed about smoking supervision and pest control |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed about resident grooming care |
| Recreation Aide #2 | Recreation Aide | Interviewed about smoking supervision |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Jun 9, 2022
Visit Reason
Inspection cited 3 standard health deficiencies related to assessments, care planning, and accident hazards, all level 2 severity and corrected by July 15, 2022.
Findings
Inspection cited 3 standard health deficiencies related to assessments, care planning, and accident hazards, all level 2 severity and corrected by July 15, 2022.
Deficiencies (3)
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: May 28, 2021
Visit Reason
The inspection was conducted based on a recertification and complaint survey to investigate allegations of deficiencies in care planning, infection control, medication administration, and pressure ulcer prevention at the facility.
Complaint Details
The complaint investigation (NY00269356) identified failures in care planning, infection control, and treatment practices affecting multiple residents, including issues with psychotropic medication monitoring, care plan development and revision, infection prevention related to IV catheters, pressure ulcer prevention, and equipment sanitation.
Findings
The facility failed to ensure accurate Minimum Data Set assessments, develop and implement comprehensive care plans with measurable goals, provide appropriate infection control practices, and prevent pressure ulcers. Deficiencies were found in medication monitoring, care plan updates, infection prevention related to IV catheters and oxygen equipment, and cleaning of reusable equipment.
Deficiencies (6)
F0641: The facility did not ensure the Minimum Data Set assessment accurately reflected a resident's status regarding Gradual Dose Reduction of psychotropic drugs.
F0656: The facility failed to develop and implement complete, person-centered care plans with measurable goals and interventions for residents' psychotropic medication, urinary tract infection, and risk for impaired skin integrity.
F0657: The facility did not ensure comprehensive care plans were reviewed and revised after catheter removal and falls for sampled residents.
F0684: The facility did not provide appropriate treatment and care for a resident with an intravenous midline catheter, failing to change dressings and monitor the catheter site for infection.
F0686: The facility failed to provide preventive skin care to a high-risk resident upon admission, resulting in moisture-associated wounds and a deep tissue injury.
F0880: The facility did not maintain infection control practices, including improper storage of oxygen and nebulizer tubing and failure to disinfect blood pressure cuffs between residents.
Report Facts
Residents reviewed for Unnecessary Medications: 5
Total investigation sample: 41
Residents sampled for care plan deficiencies: 38
Residents reviewed for Infection/Transmission-Based Precautions: 3
Residents observed for medication pass: 26
Days of antibiotic treatment: 35
Dates of midline catheter dressing observed: May 5, 2021
Dates of oxygen tubing observed on floor: May 25, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Interviewed regarding resident medication and care plan monitoring. |
| RN #1 | Registered Nurse | Interviewed regarding resident medication and care plan monitoring. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding care plan responsibilities and deficiencies. |
| Associate Director of Nursing Services (ADNS) | Associate Director of Nursing Services | Interviewed regarding wound care and care plan oversight. |
| Wound Care Nurse | Wound Care Nurse | Interviewed regarding skin breakdown prevention and care plans. |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding IV antibiotic administration and dressing changes. |
| RN #4 | Registered Nurse | Interviewed regarding IV antibiotic administration and care plan updates. |
| Nurse Practitioner (NP) | Nurse Practitioner | Interviewed regarding orders and care for midline catheter. |
| LPN #2 | Licensed Practical Nurse | Observed and interviewed regarding medication pass and equipment cleaning. |
| RN #3 | Registered Nurse Unit Manager | Interviewed regarding infection control education and monitoring. |
| ADNS/ICP | Assistant Director of Nursing / Infection Control Preventionist | Interviewed regarding infection control protocols and monitoring. |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jan 18, 2019
Visit Reason
The survey was conducted as a re-certification survey to assess compliance with health and safety regulations, including food safety and infection control practices.
Findings
The facility failed to maintain proper cold food temperatures, specifically tuna salad was found at 46°F instead of below 40°F. Infection control deficiencies were noted, including Foley catheter drainage bags and tubing resting on the floor and staff not consistently using Personal Protective Equipment (PPE) when caring for a resident on contact precautions for MRSA in sputum.
Deficiencies (2)
F0812: The facility did not ensure cold food was maintained at proper temperature; tuna salad temperature was 46°F, exceeding the required 41°F or below.
F0880: The facility failed to implement infection prevention and control practices; Foley catheter drainage bag and tubing were observed touching the floor, and staff did not consistently wear PPE when caring for a resident on contact precautions for MRSA.
Report Facts
Temperature of tuna salad: 46
Temperature range when tuna salad placed in refrigerator: 54
Temperature range when tuna salad placed in refrigerator: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Food Service | Interviewed regarding tuna salad temperature and food safety procedures | |
| Cook | Interviewed about preparation and temperature of tuna salad | |
| Dietary Aide | Interviewed about sandwich preparation and temperature checks | |
| LPN #3 | Licensed Practical Nurse - Charge Nurse | Interviewed about Foley catheter drainage bag placement and infection control |
| CNA #5 | Certified Nursing Assistant - Day Shift | Interviewed about Foley catheter drainage bag placement |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding PPE use and infection control for MRSA resident |
| CNA #2 | Certified Nursing Assistant | Observed and interviewed regarding PPE use and infection control for MRSA resident |
| RN #1 | Registered Nurse | Interviewed regarding MRSA resident care and PPE policies |
| RN #2 | Registered Nurse | Interviewed regarding MRSA resident care and PPE policies |
| RN #3 | Registered Nurse | Interviewed regarding MRSA resident care, PPE policies, and infection control training |
| RN #4 | Registered Nurse | Interviewed regarding PPE use and MRSA resident care |
| MD | Medical Doctor | Interviewed regarding MRSA resident treatment and PPE orders |
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