Inspection Reports for
Crown Heights Center for Nursing and Rehabilitation
NY, 11213
Back to Facility Profile5 Reports
Inspection Report — Feb 4, 2026
Complaint Investigation State
Date: Feb 4, 2026
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2026 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 72 complaints about this facility; 7 led to on-site inspections.
Findings
Across 4 inspections, 58 citations were issued including 32 standard health and 26 Life Safety Code citations. Most deficiencies were Level 2 with minor potential harm, and one enforcement action with fines related to infection control was recorded.
Citations (46)
Care Plan Timing And Revision: Standard Health Citation — quality of care with isolated minor potential harm.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with isolated minor potential harm.
Notify Of Changes (injury/decline/room, Etc.): Standard Health Citation — quality of care with isolated minor potential harm.
Quality Of Care: Standard Health Citation — quality of care with isolated minor potential harm.
Resident Records - Identifiable Information: Standard Health Citation — quality of care with isolated minor potential harm.
Accuracy Of Assessments: Standard Health Citation — quality of care with isolated minor potential harm.
Activities Meet Interest/needs Each Resident: Standard Health Citation — quality of care with isolated minor potential harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with pattern minor potential harm.
Free Of Accident Hazards/supervision/devices: Standard Health Citation — quality of care with isolated minor potential harm.
Infection Control: Standard Health Citation — quality of care with pattern minor potential harm.
Infection Prevention & Control: Standard Health Citation — quality of care with isolated minor potential harm.
Investigate/prevent/correct Alleged Violation: Standard Health Citation — quality of care with pattern minor potential harm.
Label/store Drugs And Biologicals: Standard Health Citation — quality of care with isolated minor potential harm.
Maintains Effective Pest Control Program: Standard Health Citation — quality of care with isolated minor potential harm.
Menus Meet Resident Nds/prep In Adv/followed: Standard Health Citation — quality of care with isolated minor potential harm.
Physician Visits - Review Care/notes/order: Standard Health Citation — quality of care with isolated minor potential harm.
Reporting Of Alleged Violations: Standard Health Citation — quality of care with pattern minor potential harm.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with pattern minor potential harm.
Building Construction Type And Height: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Electrical Systems - Other: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Fire Alarm System - Out Of Service: Life Safety Code Citation — NFPA requirements with widespread potential for minimal harm.
Hazardous Areas - Enclosure: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Illumination Of Means Of Egress: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Means Of Egress - General: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Portable Fire Extinguishers: Life Safety Code Citation — NFPA requirements with widespread minor potential harm.
Sprinkler System - Installation: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Sprinkler System - Out Of Service: Life Safety Code Citation — NFPA requirements with widespread potential for minimal harm.
Stairways And Smokeproof Enclosures: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with pattern minor potential harm.
Infection Prevention & Control: Standard Health Citation — quality of care with isolated minor potential harm.
Label/store Drugs And Biologicals: Standard Health Citation — quality of care with isolated minor potential harm.
Maintains Effective Pest Control Program: Standard Health Citation — quality of care with isolated minor potential harm.
Provision Of Medically Related Social Service: Standard Health Citation — quality of care with isolated minor potential harm.
Quality Of Care: Standard Health Citation — quality of care with isolated minor potential harm.
Resident Call System: Standard Health Citation — quality of care with isolated minor potential harm.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with isolated minor potential harm.
Safe/functional/sanitary/comfortable Environ: Standard Health Citation — quality of care with isolated minor potential harm.
Corridor - Doors: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Electrical Equipment - Other: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Exit Signage: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Fire Alarm System - Testing And Maintenance: Life Safety Code Citation — NFPA requirements with widespread potential for minimal harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation — NFPA requirements with isolated minor potential harm.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 58
Inspections with violations: 3
Inspections without violations: 1
Total complaints: 72
On-site complaint inspections: 7
Citations from complaints: 16
Total enforcement actions: 1
Total fines: 2000
Inspection Report — Dec 19, 2024
Complaint Investigation CMS
Date: 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.
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.
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.
Citations (3)
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 — Dec 19, 2024
Recertification CMS
Date: 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.
Citations (12)
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.
Failure to timely report alleged abuse and injury of unknown origin to the New York State Department of Health within required timeframes.
Failure to thoroughly investigate allegations of abuse and injury of unknown origin including resident-to-resident altercations and injuries.
Minimum Data Set assessments did not accurately reflect residents' status including preferred activities and use of wander guard alarm.
Failure to provide ongoing activity programs that meet residents' preferences and interests, including lack of television sets and no alternate activities offered.
Resident #24, cognitively impaired with agitated behaviors, sustained a laceration and fracture to toes due to inadequate supervision to prevent accidents.
Physician did not review or provide orders for dialysis care and monitoring for Resident #71.
Expired medications including Heparin flush syringes and intravenous fluids were stored in medication rooms, posing risk to resident safety.
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.
Infection prevention and control practices were not maintained including failure of staff to perform hand hygiene between residents and improper wound care practices.
Menus were not followed; food items were omitted or substituted without informing residents and without documentation of substitutions.
Facility did not maintain an effective pest control program; live rodent caught in dining room trap and flies observed on units.
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 — Nov 1, 2022
Annual Inspection CMS
Date: 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.
Citations (8)
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.
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.
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.
Expired medications and supplies were found in the medication room, and narcotic medications were not stored under double lock in the medication cart.
Expired food items (chocolate cake mix) were found in the kitchen dry storage room.
A resident was observed with a non-functioning call bell in place, preventing adequate communication for assistance.
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.
The facility did not maintain an effective pest control program, with roaches and fruit flies observed in resident rooms.
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 — Oct 28, 2020
Annual Inspection CMS
Date: 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.
Citations (4)
Failure to properly hold, secure, and manage each resident's personal money by not providing quarterly financial statements to residents.
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.
Failure to provide appropriate care for residents with nephrostomy urinary catheters, specifically improper positioning of urinary collection bags compromising gravity drainage.
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.
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 |
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