Inspection Reports for Concord Nursing and Rehabilitation Center
300 Madison Street, Brooklyn, NY, 11216
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 1, 2025, identified a deficiency related to inadequate supervision of a resident at risk of elopement. Earlier inspections showed a pattern of deficiencies involving care plan reviews, infection prevention and control, medication security, physical restraints, and environmental safety, with most issues corrected promptly. Complaint investigations were generally unsubstantiated or resulted in minor citations, with no fines or enforcement actions listed in the available reports. Prior findings included lapses in documentation and care plan updates, as well as some safety and infection control concerns. The facility’s record shows ongoing challenges in care planning and safety oversight, with corrective actions implemented after each inspection but no clear trend of sustained improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 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
16
12
8
4
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 1, 2025
Visit Reason
The abbreviated survey was conducted to evaluate compliance with safety and supervision requirements related to resident elopement risk, specifically following an incident involving Resident #2 who exited the facility undetected.
Findings
The facility failed to ensure adequate supervision of a resident identified as an elopement risk, resulting in the resident leaving the building undetected by staff. The investigation found that alarms were not properly responded to and staff did not conduct appropriate head counts or searches. Corrective actions were implemented including policy reviews, staff in-service training, elopement drills, and physical security improvements.
Deficiencies (1)
Failed to ensure that a resident identified as an elopement risk received adequate supervision to prevent elopement from the facility.
Report Facts
Residents sampled: 5
Residents at risk for elopement: 17
Staff in-serviced: 100
Enhanced monitoring frequency: 30
Incident time: 1240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Documented resident assessment and return after elopement |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Assigned to Resident #2 during shift and corridor monitoring |
| Administrator | Administrator | Provided information about alarm system and incident |
| Director of Nursing | Director of Nursing | Reported on resident elopement and staff response |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Heard alarm and searched corridor but did not find resident |
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Reported not hearing alarm and staff communication |
| Physician #2 | Physician | Assessed resident after elopement incident |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Performed rounding and observed resident after return |
| Security Officer #1 | Security Officer | Did not hear alarm or receive alert during incident |
| Security Officer #3 | Security Officer | Heard alarm panel but did not see resident on cameras |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Jul 26, 2024
Visit Reason
Inspection found multiple standard health and life safety code deficiencies, all corrected by early September 2024.
Findings
Inspection found multiple standard health and life safety code deficiencies, all corrected by early September 2024.
Deficiencies (13)
Infection prevention & control
Label/store drugs and biologicals
Right to be free from physical restraints
Right to survey results/advocate agency info
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Electrical systems - receptacles
Ep testing requirements
Ep training and testing
Hazardous areas - enclosure
Physical environment
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 26, 2024
Visit Reason
The inspection was conducted as a Recertification Survey from 07/21/2024 to 07/26/2024 to assess compliance with federal and state regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, improper use of physical restraints without proper documentation, unsecured medication storage, lapses in infection prevention and control practices including improper urinary drainage bag placement and inadequate hand hygiene, and an incomplete water management plan for Legionella.
Deficiencies (6)
Failure to ensure notice of survey results was posted in prominent and accessible areas for residents and visitors.
Resident #106 was physically restrained with a mitten on the right hand without documented assessment, care plan, physician's order, or monitoring.
Medications for Resident #14 were left unattended and unsecured on top of the medication cart for over 15 minutes.
Resident #27's urinary drainage bag was repeatedly observed on the floor, increasing infection risk.
Registered Nurse #2 failed to perform hand hygiene between glove changes during gastrostomy dressing change for Resident #80.
The facility's water management plan for Legionella lacked specification of acceptable pathogen levels.
Report Facts
Residents reviewed for restraints: 29
Units observed for medication storage: 3
Residents reviewed for urinary catheter: 29
Residents observed for nutrition investigation: 4
Dates of survey: 07/21/2024 to 07/26/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #6 | Applied mitten to Resident #106's right hand without documented orders. | |
| Registered Nurse #3 | Unit Supervisor | Aware of mitten use on Resident #106 but thought proper orders were in place. |
| Director of Rehabilitation | Stated Resident #106 unable to remove mitten and did not recommend further rehab. | |
| Nurse Practitioner #1 | Observed Resident #106 with mitten but did not order its use. | |
| Director of Nursing | Unaware of mitten use on Resident #106; stated it is a physical restraint if resident cannot remove it. | |
| Licensed Practical Nurse #2 | Left Resident #14's medications unattended on medication cart; did not check urinary drainage bag placement for Resident #27. | |
| Registered Nurse Supervisor #1 | Stated medications must be secured and noted urinary drainage bag placement issues. | |
| Certified Nursing Assistant #2 | Observed Resident #27's urinary drainage bag on floor and stated they had been educated on proper placement. | |
| Registered Nurse #2 | Failed to perform hand hygiene between glove changes during gastrostomy dressing change for Resident #80. | |
| Infection Preventionist | Stated hand washing is most important to minimize cross infection. | |
| Administrator | Committed to ensuring water management plan includes all required components. | |
| Director of Nursing Services | Stated medications should not be left unattended and must be locked. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jul 12, 2024
Visit Reason
Two standard health deficiencies related to care plan timing and resident records, corrected by late July 2024.
Findings
Two standard health deficiencies related to care plan timing and resident records, corrected by late July 2024.
Deficiencies (2)
Care plan timing and revision
Resident records - identifiable information
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jul 12, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate compliance with care plan review and medical record documentation requirements, specifically focusing on care plan updates and medical record accuracy for Resident #1.
Findings
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team to reflect changes in Resident #1's condition, specifically discolorations on the left toes. Additionally, the facility did not ensure that Resident #1's medical record accurately reflected assessments and changes in condition, as the Primary Medical Doctor did not document their assessment on 06/21/2024.
Deficiencies (2)
Care plans were not reviewed and revised by the interdisciplinary team to reflect discolorations on Resident #1's left toes.
Resident medical record did not accurately reflect the resident's current condition; Primary Medical Doctor did not document assessment on 06/21/2024.
Report Facts
Residents Affected: 1
Care Plan Revision Date: Jul 10, 2024
Physician's Order Date: Jun 21, 2024
Physician's Progress Note Date: Jun 22, 2024
Nursing Progress Note Date: Jun 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Primary Medical Doctor #1 | Primary Medical Doctor | Assessed Resident #1 but did not document assessment on 06/21/2024 |
| Regional Registered Nurse | Regional Registered Nurse | Responsible for updating care plans; unaware of discolorations until 07/10/2024 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Informed Primary Medical Doctor #1 of discoloration on 06/21/2024; not available for interview |
| Director of Nursing | Director of Nursing | Stated staff should have documented the order for Arterial Doppler Study in medical record |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Jun 8, 2022
Visit Reason
Multiple standard health and life safety code deficiencies found, including care plan, mobility, resident records, building construction, electrical systems, hazardous areas, fire extinguishers, sprinklers, and vertical openings; all corrected by mid-July 2022.
Findings
Multiple standard health and life safety code deficiencies found, including care plan, mobility, resident records, building construction, electrical systems, hazardous areas, fire extinguishers, sprinklers, and vertical openings; all corrected by mid-July 2022.
Deficiencies (10)
Care plan timing and revision
Increase/prevent decrease in rom/mobility
Resident records - identifiable information
Building construction type and height
Electrical systems - essential electric syste
Hazardous areas - enclosure
Portable fire extinguishers
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 8, 2022
Visit Reason
The inspection was a recertification survey conducted from June 1, 2022 to June 8, 2022 to assess compliance with regulatory requirements for Concord Nursing and Rehabilitation Center.
Findings
The facility was found deficient in several areas including failure to review and revise a resident's Comprehensive Care Plan (CCP) after assessments, inadequate care to maintain range of motion for a resident with contractures, and incomplete medical records related to medication administration documentation.
Deficiencies (3)
Failure to ensure a resident's Comprehensive Care Plan was reviewed and revised after each assessment, including comprehensive and quarterly reviews, specifically for pressure ulcers.
Failure to provide appropriate care to maintain or improve range of motion for a resident with bilateral hand contractures, as gauze rolls were not applied as per medical doctor order.
Failure to maintain complete medical records, specifically no documented evidence that a resident received hypertensive medication as ordered on multiple occasions.
Report Facts
Deficiencies cited: 3
Medication administration omissions: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding care plan update responsibilities and stated they can update CCPs but are not responsible for Resident #87's unit. |
| RNM | Registered Nurse Manager | Responsible for Resident #87's unit and updating CCPs; unable to find documented evidence of CCP updates after 10/29/2021. |
| DNS | Director of Nursing Services | Interviewed and stated RN unit manager is responsible for updating resident CCPs quarterly, annually, and with condition changes. |
| CNA #1 | Certified Nursing Assistant | Interviewed and confirmed Resident #41 was observed without hand rolls as ordered. |
| DOR | Director of Rehabilitation | Interviewed and stated occupational therapy recommended hand rolls for Resident #41 and rehabilitation audits adaptive devices monthly. |
| LPN #3 | Licensed Practical Nurse | Interviewed and stated nurses are responsible for checking adaptive devices and signing treatment records. |
| LPN #2 | Licensed Practical Nurse | Interviewed and described medication administration and documentation procedures. |
| RNM | Registered Nurse Manager | Interviewed about medication administration documentation and responsibility for ensuring MAR completion. |
| DON | Director of Nursing | Interviewed and described electronic medical record system for tracking MAR documentation and follow-up. |
| LPN #1 | Licensed Practical Nurse | Interviewed and stated Resident #72 does not refuse medication and refusals would be documented. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 21, 2019
Visit Reason
The inspection was conducted as part of the recertification and abbreviated survey to assess compliance with regulatory requirements, including investigation of an incident involving a resident found with a sheet tied around his neck.
Complaint Details
The visit was complaint-related due to an incident reported by a resident's wife on 1/9/2019, where the resident was found with a sheet tied around his neck. The investigation concluded no abuse but identified deficiencies in the investigation process and staff practices.
Findings
The facility failed to thoroughly investigate an incident involving a resident with a sheet tied around his neck, did not develop timely and comprehensive care plans for several residents, and did not maintain an effective infection prevention and control program, including failure to ensure proper use of PPE and outdated infection control policies.
Deficiencies (6)
Failure to ensure a thorough investigation of an incident involving a resident found with a sheet tied around his neck, including lack of staff statements from all witnesses and previous shift.
Failure to complete and transmit Minimum Data Set (MDS) assessments in a timely manner, specifically a discharge assessment over 120 days late.
Failure to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident.
Failure to develop and implement comprehensive person-centered care plans for residents, including those with limited range of motion, Foley catheter, and receiving antipsychotic medications.
Failure to maintain a nursing home environment free from accident hazards, specifically use of flat sheets tied to air mattresses instead of fitted sheets, resulting in a resident being found with a sheet tied around his neck.
Failure to maintain an infection prevention and control program, including staff and visitor failure to wear proper PPE when entering rooms of residents on contact precautions, and failure to update infection control policies annually.
Report Facts
Residents reviewed: 53
Discharge assessment delay: 120
Visual checks frequency: 15
Out of bed time: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Provided details about the incident involving Resident #390 and sheet tied around neck |
| RN #5 | Registered Nurse Supervisor | Conducted assessment and investigation of Resident #390 incident |
| CNA #5 | Certified Nursing Assistant | Described mattress sheet tying practice and resident behaviors |
| CNA #7 | Certified Nursing Assistant | Provided information about monitoring Resident #390 and sheet tying practice |
| Director of Nursing | Director of Nursing | Provided information on incident reporting, investigation, and infection control policies |
| Social Worker | Social Worker | Provided emotional support to resident's wife and described resident's condition |
| RN #1 | Registered Nurse | Discussed care plan development and deficiencies |
| Assistant Administrator | Assistant Administrator | Discussed staff training and facility culture changes |
| LPN #1 | Licensed Practical Nurse | Observed not wearing PPE when entering resident room on contact precautions |
| Nun | Visitor providing pastoral care | Observed not wearing PPE when entering resident room on contact precautions |
| Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged infection control policies were not up to date |
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