Inspection Reports for The Heritage Rehabilitation and Health Care Center
5606 15th Ave, Brooklyn, NY, 11219
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 5
Date: May 15, 2025
Visit Reason
Certification Survey with 2 health and 3 life safety code citations, all corrected by June 2025.
Findings
Certification Survey with 2 health and 3 life safety code citations, all corrected by June 2025.
Deficiencies (5)
Activities daily living (adls)/mntn abilities
Baseline care plan
Electrical systems - essential electric syste
Portable fire extinguishers
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 15, 2025
Visit Reason
The inspection was conducted as a Recertification Survey from 05/12/2025 to 05/15/2025 to assess compliance with regulatory requirements for The Heritage Rehabilitation and Health Care Center.
Findings
The facility was found deficient in completing baseline care plans within 48 hours of admission and in providing adequate communication services, including interpreter services, for a non-English speaking resident. These deficiencies were noted for Resident #327, who did not have a timely baseline care plan and was not provided interpreter services during the admission nutrition assessment.
Deficiencies (2)
Baseline care plan was not completed within 48 hours of Resident #327's admission, completed four days after admission.
Resident #327, whose primary language is Cantonese, was not provided with interpretation services during the admission nutrition assessment.
Report Facts
Residents reviewed for Communication: 20
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Interviewed regarding baseline care plan completion and notification process | |
| Director of Social Work | Interviewed about baseline care plan completion and work schedule | |
| Registered Dietitian | Interviewed about baseline care plan completion and use of language line | |
| Director of Rehab | Interviewed about baseline care plan completion and weekend staffing | |
| Recreation Director | Interviewed about baseline care plan completion and weekend staffing | |
| Director of Nursing | Interviewed about responsibility for baseline care plan oversight and weekend staffing | |
| Administrator | Interviewed about admission process and baseline care plan completion timing | |
| Certified Nursing Assistant #1 | Interviewed regarding care of Resident #327 and language abilities |
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
Abuse reporting documentation deficiency noted.
Findings
Abuse reporting documentation deficiency noted.
Deficiencies (1)
R9-10-803.J — Abuse reporting documentation
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Aug 17, 2023
Visit Reason
Complaint Survey with 1 health and 1 life safety code citation, both corrected by September 2023.
Findings
Complaint Survey with 1 health and 1 life safety code citation, both corrected by September 2023.
Deficiencies (2)
Menus meet resident nds/prep in adv/followed
Electrical systems - essential electric syste
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as a Recertification Survey from 08/10/2023 to 08/17/2023 to assess compliance with nutritional needs and meal service standards for residents.
Findings
The facility failed to ensure that menus were followed as required, resulting in Resident #9 not receiving items listed on their tray tickets during multiple meal observations. Despite documented dietary orders and preferences, the resident was served incorrect meals, including missing soft food items and scrambled eggs.
Deficiencies (1)
Menus were not followed, resulting in Resident #9 not receiving items listed on their tray ticket during mealtimes.
Report Facts
Residents reviewed for food: 20
Residents with food issues: 1
Dates of survey: 08/10/2023 to 08/17/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistance (CNA) #1 | Interviewed regarding meal tray checks and communication with kitchen | |
| Certified Nursing Assistance (CNA) #2 | Interviewed regarding familiarity with Resident #9's preferences and tray accuracy | |
| Registered Nurse (RN) #1 | Interviewed regarding awareness of Resident #9's food preferences and meal tray checks | |
| Dietary Aide (DA) #1 | Interviewed regarding tray setup and accuracy checks | |
| Registered Dietician (RD) | Interviewed regarding Resident #9's diet and food preferences | |
| Food Service Manager (FSM) | Interviewed regarding awareness of Resident #9's food preferences and meal tray monitoring |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 30
Date: Nov 26, 2021
Visit Reason
Complaint Survey with multiple health and life safety code citations including an immediate jeopardy Level 4 deficiency related to physical restraints; all corrected by early 2022.
Findings
Complaint Survey with multiple health and life safety code citations including an immediate jeopardy Level 4 deficiency related to physical restraints; all corrected by early 2022.
Deficiencies (30)
Care plan timing and revision
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
General requirements
Increase/prevent decrease in rom/mobility
Infection prevention & control
Investigate/prevent/correct alleged violation
Physician visits - review care/notes/order
Qapi/qaa improvement activities
Request/refuse/dscntnue trmnt;formlte adv dir
Resident rights/exercise of rights
Right to be free from physical restraints
Safe/clean/comfortable/homelike environment
Safe/functional/sanitary/comfortable environ
Corridors - construction of walls
Egress doors
Electrical equipment - power cords and extens
Electrical systems - other
Emergency lighting
Fire alarm system - installation
Hazardous areas - enclosure
Illumination of means of egress
Means of egress - general
Organization and administration
Physical environment
Sprinkler system - installation
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Nov 26, 2021
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, advance directives documentation, environmental cleanliness, physical restraint use, abuse investigation, care plan participation, physician review of care, infection control, and safety of the facility environment.
Deficiencies (11)
Resident's right to a dignified existence was not respected; a photograph and identifying information of a resident was posted in a public area.
Resident's wishes for Advance Directives were not ordered and correctly identified; inconsistency between Physician's orders and MOLST form.
Facility did not ensure a safe, clean, comfortable, and homelike environment; dirty floors, torn wallpaper, stained toilet doors, and delayed maintenance.
Residents were restrained with physical restraints without adequate assessment, physician orders, or timely release; immediate jeopardy identified.
Facility failed to thoroughly investigate alleged abuse and neglect; injury of unknown origin was not investigated.
Residents and representatives were not consistently involved in developing the comprehensive care plan or invited to care plan meetings.
Facility did not ensure appropriate equipment to maintain or improve mobility; resident at risk for contracture observed without ordered handroll in place.
Physician did not review resident's care, write, sign, and date progress notes and orders at each required visit; no documented assessment of physical restraint use for residents with restraints.
Quality Assessment and Assurance committee failed to develop and implement effective corrective plans for identified quality deficiencies related to physical restraint and side rail use.
Facility failed to maintain infection control standards; entertainer observed without face covering and staff failed to use appropriate PPE with resident on contact/droplet precautions.
Patio exit door was unsecured with non-functioning alarm and door hardware, allowing residents to exit unattended.
Report Facts
Deficiencies cited: 11
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse Supervisor | Named in physical restraint findings and physician communication |
| RN #2 | Registered Nurse | Named in physical restraint and infection control findings |
| RN #3 | Registered Nurse | Named in dignity and abuse investigation findings |
| Director of Nursing (DON) | Director of Nursing | Named in multiple findings including restraint, care plan, and infection control |
| Medical Director | Medical Director | Named in restraint and physician review findings |
| Attending Physician #1 | Attending Physician | Named in restraint and physician review findings |
| Attending Physician #2 | Physician | Named in abuse investigation findings |
| CNA #13 | Certified Nursing Assistant | Named in restraint and infection control findings |
| CNA #15 | Certified Nursing Assistant | Named in restraint and patio door findings |
| OT #1 | Occupational Therapist | Named in infection control findings |
| LPN | Licensed Practical Nurse | Named in abuse investigation findings |
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