Inspection Reports for
The Heritage Rehabilitation and Health Care Center
5606 15th Ave, Brooklyn, NY, 11219
Back to Facility ProfileInspection Report — May 15, 2025
Annual Inspection
Citations: 7
Date: May 15, 2025
Visit Reason
State-compiled facility profile showing 2 inspections from 2023 to 2025 with deficiency history and enforcement actions.
Complaint Details
The state logged 13 complaints about this facility; 1 led to on-site inspections. No citations resulted from those complaints.
Findings
Across 2 inspections in the reporting period, inspectors issued 9 citations including 5 standard health and 4 Life Safety Code citations. The facility had 13 complaints with 1 on-site inspection and 1 enforcement action with fines recorded.
Citations (7)
Standard Health Citation — quality of care: Activities Daily Living (adls)/mntn Abilities deficiency noted.
Standard Health Citation — quality of care: Baseline Care Plan deficiency noted.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System deficiency noted.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers deficiency noted.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures deficiency noted.
Standard Health Citation — quality of care: Menus Meet Resident Nds/prep In Adv/followed deficiency noted.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System deficiency noted.
Report Facts
Inspections on page: 2
Total violations/deficiencies cited: 9
Inspections with violations: 2
Inspections without violations: 0
Total complaints: 13
On-site complaint inspections: 1
Total enforcement actions: 1
Total fines: 12000
Inspection Report — Aug 17, 2023
Annual Inspection
Citations: 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.
Citations (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 — Nov 26, 2021
Annual Inspection
Citations: 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.
Citations (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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