Inspection Reports for Crown Heights Center for Nursing and Rehabilitation
NY, 11213
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
259% 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: 25
Dec 19, 2024
Visit Reason
Inspection identified 13 health and 12 life safety code deficiencies related to quality of care and safety, all corrected by February 19, 2025.
Findings
Inspection identified 13 health and 12 life safety code deficiencies related to quality of care and safety, all corrected by February 19, 2025.
Deficiencies (25)
| Description |
|---|
| Accuracy of assessments |
| Activities meet interest/needs each resident |
| Food procurement, store/prepare/serve-sanitary |
| Free of accident hazards/supervision/devices |
| Infection control |
| Infection prevention & control |
| Investigate/prevent/correct alleged violation |
| Label/store drugs and biologicals |
| Maintains effective pest control program |
| Menus meet resident needs/prep in advance/followed |
| Physician visits - review care/notes/order |
| Reporting of alleged violations |
| Safe/clean/comfortable/homelike environment |
| Building construction type and height |
| Electrical equipment - power cords and extens |
| Electrical systems - other |
| Fire alarm system - out of service |
| Hazardous areas - enclosure |
| Illumination of means of egress |
| Means of egress - general |
| Portable fire extinguishers |
| Sprinkler system - installation |
| Sprinkler system - maintenance and testing |
| Sprinkler system - out of service |
| Stairways and smokeproof enclosures |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 19, 2024
Visit Reason
The inspection was conducted as a Recertification/Complaint survey from 12/12/2024 to 12/19/2024 to investigate multiple complaints including environmental safety concerns and allegations of abuse and injury of unknown origin.
Findings
The facility was found to have multiple environmental deficiencies including damaged furniture, missing tiles, dirty equipment, and unsafe conditions. Additionally, the facility failed to timely report and thoroughly investigate several incidents of injury of unknown origin and resident-to-resident physical abuse involving multiple residents. Incident reports were incomplete or missing, and some injuries were not reported to the New York State Department of Health as required.
Complaint Details
The complaint investigation revealed that Resident #251 sustained an unwitnessed injury to the forehead that was not reported timely. Resident-to-resident physical abuse involving Residents #214, #268, and #589 was not reported timely and was not thoroughly investigated. Resident #24 sustained a foot injury that was not reported to the Department of Health. Incident reports were incomplete or missing, and the facility failed to interview all relevant staff or include all involved residents in investigations.
Deficiencies (3)
| Description |
|---|
| Multiple environmental safety issues including scratched furniture, missing handles, damaged drywall, missing and cracked tiles, dirty whirlpool tub, rusty stairs, and stained equipment. |
| Failure to timely report injuries of unknown origin and resident-to-resident physical abuse to the New York State Department of Health within required timeframes. |
| Failure to thoroughly investigate allegations of abuse and injury of unknown origin, including incomplete incident reports and lack of interviews with involved staff. |
Report Facts
Number of residents involved in abuse incident: 3
Size of hematoma: 7
Number of missing tiles: 20
Number of broken tiles: 4
Number of residents sampled: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | Observed Resident #251 with bump on forehead and reported incident. | |
| Assistant Director of Nursing | Responsible for summarizing incident reports and aware of reporting requirements; investigated abuse incidents. | |
| Director of Nursing | Reviewed incidents, decided some were not reportable, and instructed supervisors to complete incident reports. | |
| Licensed Practical Nurse #5 | Witnessed resident-to-resident abuse incident and called for emergency response. | |
| Maintenance Director | Conducted rounds and inspected radiator involved in Resident #24 injury. | |
| Registered Nurse Supervisor #3 | Managed unit when Resident #251 injury was observed and reported incident to Assistant Director of Nursing. | |
| Nurse Practitioner | Evaluated Resident #251 after injury and ordered hospital transfer. | |
| Rehab Director | Followed up on Resident #251 incident and believed it should have been reported. | |
| Administrator | Reviewed incident investigation and was aware of Resident #251 injury. |
Inspection Report
Recertification
Deficiencies: 12
Dec 19, 2024
Visit Reason
The survey was conducted as a Recertification Survey from 12/12/2024 to 12/19/2024 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and homelike environment; failure to timely report and thoroughly investigate abuse and injury of unknown origin; inaccurate Minimum Data Set assessments; failure to provide activities meeting residents' preferences; inadequate supervision to prevent accidents; improper medication storage including expired medications; failure to follow menus and provide substitutions; lapses in infection control practices; and ineffective pest control program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility did not maintain a safe, clean, comfortable, and homelike environment with multiple observations of damaged furniture, missing paint, holes in walls, dirty whirlpool tub, rusty steps, and stained equipment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report alleged abuse and injury of unknown origin to the New York State Department of Health within required timeframes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate allegations of abuse and injury of unknown origin including resident-to-resident altercations and injuries. | Level of Harm - Minimal harm or potential for actual harm |
| Minimum Data Set assessments did not accurately reflect residents' status including preferred activities and use of wander guard alarm. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide ongoing activity programs that meet residents' preferences and interests, including lack of television sets and no alternate activities offered. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #24, cognitively impaired with agitated behaviors, sustained a laceration and fracture to toes due to inadequate supervision to prevent accidents. | Level of Harm - Minimal harm or potential for actual harm |
| Physician did not review or provide orders for dialysis care and monitoring for Resident #71. | Level of Harm - Minimal harm or potential for actual harm |
| Expired medications including Heparin flush syringes and intravenous fluids were stored in medication rooms, posing risk to resident safety. | Level of Harm - Minimal harm or potential for actual harm |
| Food was not stored, prepared, distributed, and served in accordance with professional standards including staff not wearing beard guards and hair restraints, and open food containers in dry storage. | Level of Harm - Minimal harm or potential for actual harm |
| Infection prevention and control practices were not maintained including failure of staff to perform hand hygiene between residents and improper wound care practices. | Level of Harm - Minimal harm or potential for actual harm |
| Menus were not followed; food items were omitted or substituted without informing residents and without documentation of substitutions. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not maintain an effective pest control program; live rodent caught in dining room trap and flies observed on units. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Expired Heparin flush syringes: 18
Heparin flush expiration dates: 2024
Intravenous fluid expiration date: 2024
Resident #251 hematoma size: 7
Resident #24 laceration size: 3
Resident #24 laceration size: 1.5
Resident #24 laceration size: 0.5
Resident #24 fracture size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Observed not performing hand hygiene between residents during dining assistance |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed not washing hands between glove changes during wound care |
| Director of Maintenance | Director of Maintenance | Interviewed regarding pest control and maintenance rounds |
| Assistant Director of Nursing | Assistant Director of Nursing/Infection Preventionist | Interviewed regarding infection control rounds and expired medication removal |
| Director of Nursing | Director of Nursing | Interviewed regarding incident reporting and wound care practices |
| Medical Doctor | Physician | Interviewed regarding Resident #71 dialysis care and Resident #251 injury assessment |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed regarding observation of Resident #251 injury |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding expired medication in medication room |
| Dietary Aide #2 | Dietary Aide | Interviewed regarding beard net use and dry storage room observations |
| Dietary Aide #3 | Dietary Aide | Interviewed regarding beard net use |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding kitchen staff uniform requirements |
| Director of Food Services | Director of Food Services | Interviewed regarding kitchen staff uniform requirements and menu substitutions |
| Wound Care Coordinator | Wound Care Coordinator | Interviewed regarding wound care training and practices |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Interviewed regarding observation of blood on floor and Resident #24's condition |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Observed expired Heparin flushes in medication room |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding intravenous medication expiration |
| Registered Nurse #7 | Registered Nurse | Interviewed regarding medication room checks |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding medication room inspections |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding Resident #436 activity and room conditions |
| Activity Leader #1 | Activity Leader | Interviewed regarding resident activities and television installation |
| Maintenance Worker #3 | Maintenance Worker | Interviewed regarding radiator inspection |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Interviewed regarding care of Resident #24 on day of accident |
| Housekeeper #2 | Housekeeper | Interviewed regarding observation of blood on floor |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding care of Resident #24 on day of accident |
| Administrator | Administrator | Interviewed regarding Resident #251 injury and incident reporting |
| Registered Nurse Manager #4 | Registered Nurse Manager | Interviewed regarding staff education on Enhanced Barrier Precautions |
| Director of Food Service | Director of Food Services | Interviewed regarding menu substitutions and food service policies |
| Dietary Aide #8 | Dietary Aide | Interviewed regarding salad preparation and availability |
Inspection Report
Annual Inspection
Deficiencies: 8
Nov 1, 2022
Visit Reason
The inspection was a Recertification survey conducted from 10/25/2022 to 11/01/2022 to assess compliance with regulatory standards for nursing home operations, including environment, treatment, medication storage, social services, pest control, and safety.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and homelike environment; ensuring appropriate treatment and care according to orders; proper medication storage; providing medically-related social services; maintaining a working call system; ensuring a safe and functional environment; and maintaining an effective pest control program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Residents' environment was not safe, clean, comfortable, and homelike with issues such as dusty and disrepair AC/heater units, stained toilets, broken lights, stained curtains, and unpainted closet doors. | Level of Harm - Minimal harm or potential for actual harm |
| Residents did not receive treatment and care according to professional standards, including use of a wander guard device without physician order and inadequate wound care documentation and treatment for a diabetic foot ulcer. | Level of Harm - Minimal harm or potential for actual harm |
| Medically-related social services failed to ensure timely transfer of deceased resident's body to the city morgue, resulting in the body remaining in the facility morgue refrigerator for 11 days. | Level of Harm - Minimal harm or potential for actual harm |
| Expired medications and supplies were found in the medication room, and narcotic medications were not stored under double lock in the medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Expired food items (chocolate cake mix) were found in the kitchen dry storage room. | Level of Harm - Minimal harm or potential for actual harm |
| A resident was observed with a non-functioning call bell in place, preventing adequate communication for assistance. | Level of Harm - Minimal harm or potential for actual harm |
| A soiled utility room door had a broken lock preventing it from closing, with soiled linen and garbage bags on the floor, posing infection control risks. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not maintain an effective pest control program, with roaches and fruit flies observed in resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 35
Units observed: 6
Expired medication items: 4
Narcotic tablets: 83
Expired food boxes: 2
Days body remained in facility morgue: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Interviewed regarding expired medications and broken narcotic compartment lock |
| Director of Nursing | Director of Nursing | Interviewed regarding morgue refrigerator capacity, family communication, and facility policies |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding soiled utility room lock and maintenance |
| Director of Maintenance | Director of Maintenance | Interviewed regarding pest control and maintenance logbooks |
| Administrator | Administrator | Interviewed regarding pest control and morgue policies |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding non-functioning call bell observation |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Interviewed regarding call bell maintenance and resident behavior |
| Director of Social Services | Director of Social Services | Interviewed regarding funeral arrangements and body pickup delays |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Jun 3, 2022
Visit Reason
Two standard health deficiencies related to ADL care for dependent residents and pharmacy services, both corrected by August 3, 2022.
Findings
Two standard health deficiencies related to ADL care for dependent residents and pharmacy services, both corrected by August 3, 2022.
Deficiencies (2)
| Description |
|---|
| ADL care provided for dependent residents |
| Pharmacy srvcs/procedures/pharmacist/records |
Inspection Report
Capacity: 60
Deficiencies: 1
Mar 14, 2022
Visit Reason
One standard health deficiency related to reporting to the national health safety network; no correction date provided.
Findings
One standard health deficiency related to reporting to the national health safety network; no correction date provided.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Annual Inspection
Deficiencies: 4
Oct 28, 2020
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in several areas including failure to provide quarterly financial statements to residents, lack of documented advance directive discussions, improper care of nephrostomy urinary catheter bags, and inadequate infection prevention practices related to oxygen and nebulizer tubing.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to properly hold, secure, and manage each resident's personal money by not providing quarterly financial statements to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to honor the resident's right to request, refuse, and/or discontinue treatment, including failure to initiate and review advance directives periodically with residents or their representatives. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care for residents with nephrostomy urinary catheters, specifically improper positioning of urinary collection bags compromising gravity drainage. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, specifically failure to properly label and date oxygen and nebulizer tubing, and tubing observed on the floor. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 40
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Social Worker | Interviewed regarding distribution of quarterly financial statements and advance directives |
| Finance Coordinator | Finance Coordinator | Interviewed regarding distribution of quarterly financial statements |
| Social Worker #3 | Social Worker | Interviewed regarding advance directive documentation |
| Administrator | Administrator | Interviewed regarding awareness of advance directive documentation issues |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding nephrostomy catheter care |
| Charge Nurse (RN #1) | RN | Interviewed regarding nephrostomy catheter care |
| Director of Nursing/Infection Control Preventionist | DNS/ICP | Interviewed regarding nephrostomy catheter care and infection control practices |
| Physician | MD | Interviewed regarding nephrostomy catheter care |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding oxygen and nebulizer tubing care |
| Registered Nurse #2 | RN | Interviewed regarding oxygen and nebulizer tubing care |
Loading inspection reports...
