Crown Heights Center for Nursing and Rehabilitatio

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (2699587), the facility failed to ensure the designated resident's representative was notified of changes in the resident's condition. This was evident for one (1) of six (6) residents sampled (Resident #1). Specifically, on 12/06/2025 at 5:00 PM Occupational Therapist Assistant #1 documented they saw Resident #1 sliding from the wheelchair to the floor. There is no documented evidence that the facility notified Resident 1's representative that Resident #1 was seen sliding out of the wheelchair to the floor.

Inspectors wroteBased on observation, record review and interview during an Abbreviated Complaint Survey (Complaint # 2699587), the facility failed to ensure resident's care plan was reviewed and revised by the interdisciplinary team after each assessment. This was evident for one (1) out of six (6) residents sampled (Resident #1). Specifically, on 12/06/2025 at 5:00 PM Occupational Therapist Assistant #1 documented they saw Resident #1 sliding from the wheelchair to the floor. Registered Nurse Supervisor #2 was notified on 12/06/2025. There was no documented evidence that Resident #1's care plan was reviewed and revised with new interventions after Resident #1 slide from the wheelchair to the floor on 12/06/2025.

Inspectors wroteBased on observation, record review and interview during an Abbreviated Complaint Survey (Complaint # 2699587), the facility failed to ensure Resident #1 received treatment and care in accordance with professional standards of practice. This was evident for one (1) of six (6) residents sampled (Resident #1). Specifically, on 12/19/2025 License Practical Nurse #2 administered a stool softener to Resident #1 without a physician's order for the stool softener. License Practical Nurse #2 did not document the administration of the stool softener to Resident #1.

Inspectors wroteBased on observation, record review and interview during Abbreviated Complaint Survey (Complaint #2699587), the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. This was evident for one (1) out of six (6) residents sampled (Resident #1). Specifically, Resident #1 was a high risk for falls, the physician's order dated 11/11/2025 documented Resident #1 may be out of bed to standard wheelchair with bilateral elevating leg rests and with manual transfer of one (1) person. On 12/06/2025 at 5:00 PM, Occupational Therapist Assistant #1 documented Resident #1 was seen sliding from the wheelchair to the floor. There is no documented evidence on the Documentation Survey Report or on the Resident Nursing Instruction form instructing staff members on how to supervise Resident #1 to prevent fall.

Inspectors wroteBased on observation, record review and interview during Abbreviated Complaint Survey (Complaint #2699587), the facility failed to ensure that medical records were maintained in accordance with accepted professional standards and practices and were accurately documented. This was evident for one (1) out of six (6) residents sampled (Resident #1). Specifically, on 12/06/2025 at 5:00 PM Occupational Therapist Assistant #1 documented they saw Resident #1 sliding from the wheelchair to the floor. There was no nursing or medical doctor's documentation in Resident #1's medical record indicating that Resident #1 was assessed after Resident #1 slide out of the wheelchair to the floor on 12/6/2025.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment was maintained. Specifically multiple observations were made of resident rooms were observed with wood furniture scratched veneer, missing key holes, missing handles to dressers or wall cabinets, bedside tables were observed with missing paint on the lower leg areas. 2.) resident rooms were observed with mismatched paint, holes in dry wall and duct tape on the floor, missing tile and/or grimy tile. 3.) resident's wheelchair was observed with torn cushion and enteral feeding pumps and poles on 2 East and 2 [NAME] unit was observed with cream-colored stains on the pump and pole bottoms. 4). [...]

Inspectors wroteBased on observation, record review and staff interview during the Recertification /Complaint survey (NY00334742) conducted between 12/12/2024 and 12/19/2024, the facility did not ensure that all alleged violations involving abuse and injury of unknown origin were reported immediately to the New York State Department of Health, but not later than 2 hours after the alleged abuse and injury were observed. Specifically, (1) an injury of unknown origin found on resident #251's forehead was not reported; (2) Resident-Resident physical abuse resulting to injury involving 3 residents was not reported (Residents #214, #268, and #589); and (3) Injury of unkown origin found on Resident #24's toes was not reported. This was evident for one of three residents investigated for complaints and 4 out of 4 residents reviewed for Accidents out of 38 sampled residents.

Inspectors wroteBased on observation, record review and staff interview during the Recertification/Complaint survey (NY00334742) conducted between 12/12/2024 and 12/19/2024, the facility did not ensure that all allegations of abuse and injury of unknown origin were thoroughly investigated. Specifically, (1) Injury of unknown origin observed on Resident #251 was not thoroughly investigated and (2). Resident-to-resident altercation involving Residents #214, #268 and #589 was not thoroughly investigated. This was evident for 1 of 3 complaint investigations and for 3 of 3 residents reviewed for Accidents out of 38 total sampled residents.

Inspectors wroteBased on observations and staff interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards of food service safety. Specifically, 1) staff was observed not wearing beard guard on multiple occasions or hair restraints appropriately in the kitchen. 2) the dry storage room was observed with an open box of beverage and food thickener was observed opened on two occasions and was noted with a paper cup in the open box while on the shelf. This was observed during the Kitchen facility task.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 2 (Resident #237 and #436) of 38 total sampled residents. Specifically, the Minimum Data Set 3.0 assessment for Resident #237 did not accurately reflect the resident's preferred activities and the Minimum Data Set 3.0 assessment for Resident #436 did not accurately reflect the resident use of wander guard as alarm.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 3 (Residents #219, #237, and #436) of 4 residents reviewed for Activities out of 38 sampled residents. Specifically, Residents #219, #237, and #436 were not provided with activities that met their preferences and interests.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 12/13/2024 to 12/19/2024, the facility did not ensure residents received adequate supervision to prevent accidents. This was evident for 1 (Resident #24) of 4 residents reviewed for accidents out of 38 total sampled residents. Specifically, Resident #24, who is cognitively impaired with agitated behaviors, sustained a laceration on right 3rd, 4th and 5th metatarsal resulting in a minimally displaced extra articular fracture of the right third and 4th proximal phalanges.

Inspectors wroteBased on observation, interview and record review conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that the physician reviewed the resident's total program of care. This was evident for 1 resident (Resident #71) of 2 residents reviewed for Dialysis, out of 38 sampled residents. Specifically, there were no physician's order for Dialysis and the care and treatment for the monitoring of the Perma Cath on Resident #71, who was on Dialysis.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. Specifically, 1) Eighteen individual expired Heparin lock flush syringes were stored on medication room on 2 [NAME] and 2 East Units. This was evident for 2 of 6 units (2 [NAME] and 2 East) during the Medication Storage Task.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure menus were followed. This was evident for 5 residents (Resident # 97, Resident # 156, Resident # 212, Resident # 252 and Resident # 271) observed during the Dining Observation task. Specifically, food items were omitted or substituted, and residents were not informed of the changes.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, (1) Certified Nursing Assistant (CNA) #8 was assisting multiple residents to perform hand hygiene in the dining room and did not clean their hands in between residents (2) Licensed Practical Nurse #3 who was observed performing wound care did not ensure infection control practices were maintained during a dressing change. This was evident during Dining Observation and Infection Control tasks.

Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident during the environmental observation. Specifically, 1) A live rodent was observe caught in a box trap in the dining room while residents were present. 2) Flies were observed flying on the units during the survey (2 [NAME] and 4 West). This was evident for the Environmental task.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 10/25/2022 to 11/07/2022, the facility did not store food in accordance with professional standards for food service safety. This was evident during kitchen observation. Specifically, expired chocolate cake mix was observed in the kitchen's Dry Storage Room (DSR).

Inspectors wroteBased on observations, record review, and interviews conducted during a Recertification survey from 10/25/22 to 11/01/22, the facility did not ensure residents' environment was safe, clean, comfortable, and homelike. This was evident for 2 (2 [NAME] and 4 West) out of 6 units. Specifically, 1) Multiple rooms on the 2 [NAME] were observed with air conditioning (AC)/heater units that were dusty, dirty, and in disrepair; and 2) 4 [NAME] resident rooms were observed with dirty toilet bowls that had brown stains, a resident's bathroom without a functioning light above the toilet bowl, a dusty and broken radiator, a stained divider curtain, and a resident's closet door was not completely painted.

Inspectors wroteBased on observation, interviews and record review conducted during an Abbreviated Recertification Survey, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #250 and Resident #201) of 35 sampled residents. Specifically, (1) Resident #250 had a wander guard in place without a current assessment or physician's order. (2) Resident #201 had a diabetic foot ulcer, and there were no wound measurement and description notes for 3 weeks. In addition, the treament record showed omissions for wound care for multiple days.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Recertification Survey and Complaint Survey (NY00303638), the facility failed to ensure medically-related social services to attain or maintain the highest practicable physical well-being of each resident were provided. This was evident for 1 out of 1 closed record reviewed for Death (Resident #468). Specifically, Resident #468 expired in the facility on [DATE], and plans coordinated with the designated representative to send Resident #468's body to the city morgue due to delays in funeral arrangements were not executed. As a result, Resident #468's body remained in the facility morgue holding refrigerator until [DATE] when their body was picked up by the funeral home.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that all medications and biologicals were stored in accordance with professional standards of practice. This was evident for 1 of 6 units (2 [NAME] Unit). Specifically, (1) a urine culture and sensitivity kit with expiration date of 06/2022 in the medication room draw, a bottle of prescribed antibiotic liquid with use by date of 10/29/2022 in the medication refrigerator, a box containing 76 suppositories with expiration date of 01/2022, and two bottles of expired iron liquid found in the medication room cabinet. (2) multiple prescribed narcotic medication was not stored under double lock in the medication cart for the lower side of the 2 [NAME] Unit. This was evident for 1 out of 6 medication rooms and 1 out of 10 medication carts. (Unit 2 West)

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 10/25/2022 to 11/1/2022, the facility did not ensure a resident was adequately equipped to call for assistance through a communication system. This was evident for 1 (Resident #254) of 35 sampled residents. Specifically, Resident #254 was observed with a non-functioning call bell in place.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 10/25/22 to 11/1/22, the facility did not ensure a safe functional environment for residents, staff, and public. This was evident for 1 (2 West) of 6 units observed. Specifically, a soiled utility room door was observed with a broken lock preventing the door from closing.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 10/25/22 to 11/1/22, the facility did not ensure it maintained an effective pest control program so that the facility is free of pests. This was evident on 1 (4 West) of 6 units. Specifically, 1) several roaches approximately 1/2 inch in length were observed in room [ROOM NUMBER] and 426, and 2) several fruit flies were noted in room [ROOM NUMBER].

Inspectors wroteBased on record review and staff interviews conducted during the Recertification Survey, the facility did not ensure that individual financial records were available to the resident through quarterly statements. Specifically, there was no documentation that a resident consistently received quarterly statements from 01/01/2020 to 10/13/2020. This was evident for 1 out of 1 resident reviewed for Personal Funds out of a sample of 40 residents (Resident #154). The finding is: The facility policy Accessing Resident Funds/Banking Hours/Quarterly Statements revised 01/02/2019 documented that quarterly statements will be delivered to the alert and oriented residents on their respective units by the Social Worker and the resident without capacity or whom family has requested for the statement to be mailed will be mailed to their address on file. [...]

Inspectors wroteBased on record review and staff interviews conducted during the Recertification Survey, the facility did not ensure that advanced directives were initiated and reviewed periodically with resident and or resident's representative. Specifically, there was no documented evidence advance directives had been discussed with the resident's representative. This was evident for 1 of 2 residents reviewed for Advance Directives out of a sample of 40 residents. (Resident # 144) The finding is : The facility policy and procedure tiled Advance Directives revised 4/2018 documented it is the policy of Crown Heights Center that its health care staff educates residents with capacity to make informed decisions about their right to: [...]

Inspectors wroteBased on observation, record review and interview conducted during the Recertification Survey, the facility did not ensure that resident received appropriate care and services to prevent urinary tract infections. Specifically, a resident's nephrostomy urinary collection bag was improperly positioned compromising the devices' ability to maintain gravity drainage and prevent reflux of urine. This was evident for 1 of 2 reviewed for Catheter care out of a sample of 40 resident, (Resident #217)

Inspectors wroteBased on observation, record review, and staff interviews during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, the residents on oxygen/nebulizer treatment were observed with the tubing not properly labeled and dated to indicate the time the tubing was replaced. This was evident in 2 of 2 residents reviewed for Respiratory Care area/Oxygen use out of a sample of 40. (Residents #372 & #376).