Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brooklyn Center For Rehabilitation And Residential during CMS and state inspections, most recent first.
A CNA took a resident's dresser key and removed $250 from the resident's wallet without consent. The resident, who was cognitively intact and had multiple medical conditions, did not immediately report the theft. Facility policies required prevention and prompt reporting of such incidents, but there was no documentation of the allegation in social service or nursing notes, and staff interviews revealed a lack of awareness about the missing property.
Medication storage was not maintained appropriately on two units. On one unit, a bag of antibiotics mixed in solution was left unattended at the nurses station while staff were away and visitors and non-nursing staff were present. On another unit, the medication room contained expired lubricant, iodine swabs, Pro Stat, and enteral feeding supplies. Staff interviews showed the items had not been secured or routinely checked as required.
Two residents who required two-person mechanical lift transfers were each transferred by a single CNA, resulting in one sustaining a humerus fracture and facial swelling, and the other a hip fracture requiring surgery. In both cases, staff failed to follow care plans and facility policy, did not immediately report the incidents, and the events were confirmed through interviews and documentation review.
The facility did not report two separate incidents in which residents sustained fractures during mechanical lift transfers within the required timeframe to state authorities. In both cases, staff and administration were aware of the reporting requirements but failed to submit reports promptly after the injuries were identified, resulting in delays of several hours to days.
A resident who required full assistance for transfers fell from a mechanical lift, sustaining a humerus fracture and facial swelling, after being transferred by only one staff member. The care plan addressing falls was not reviewed or revised following the incident, and both nursing staff and the DON confirmed that no updates were made to reflect the resident's changed condition or new interventions.
A resident who required two staff for mechanical lift transfers was moved from the floor back to bed by two CNAs without a nursing assessment after a fall caused by a single CNA attempting the transfer alone. Facility policy requiring nurse evaluation before moving a resident after an accident was not followed, and the resident was later found to have sustained a hip fracture.
A resident with severe cognitive impairment and hemiplegia was not provided with required knee and elbow braces as outlined in their care plan. Multiple staff members, including CNAs and LPNs, were unaware of the need to apply these devices, and the instructions were not visible in the electronic medical record. The devices were found unused in the resident's closet, and there was no documentation of their application over several months.
Failure to Prevent Misappropriation of Resident Property by Staff
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) removed a resident's dresser key from their arm, accessed the locked dresser, and took $250 from the resident's wallet without consent. The resident, who had diagnoses including COPD, heart failure, anxiety, and depression, was cognitively intact and required varying levels of assistance with activities of daily living. The incident was not immediately reported by the resident, who initially waited to inform their family but later reported the theft to nursing staff after returning from a medical appointment. Facility policies required the prevention, prompt investigation, and reporting of misappropriation of resident property, including notification to appropriate agencies within 24 hours. Despite these policies, there was no documentation in the social service or nursing notes regarding the resident's allegation of stolen money. The CNA involved was assigned to the resident's unit during the relevant shift, and the resident later identified the CNA as the individual who took the money. The CNA denied the allegation during an interview but acknowledged receiving training on abuse and misappropriation of resident funds. Interviews with facility staff revealed a lack of awareness regarding the missing property, and no audits or reports of missing money were noted for the unit. The incident was eventually reported to supervisory staff and law enforcement after the resident's family became involved. The facility's failure to ensure the resident was free from misappropriation of property constituted a violation of regulatory requirements.
Medication Storage Lapses and Expired Supplies Found in Medication Areas
Penalty
Summary
Drugs and biologicals were not stored appropriately on Unit 2 and Unit 1. On Unit 2, a bag of medication containing 4 vials of antibiotics mixed in solution was observed unattended on a desk at the nurses station while nursing staff were in the dining room, an LPN was leaving the nurses station, and non-nursing staff and visitors were on the unit. The LPN on orientation stated the medication had been delivered about an hour earlier before the evening shift nurse came on duty and should have been secured, but staff had not yet placed it in the medication cart because they were serving supper. Another LPN stated delivered medication should be taken and placed in the medication cart because it contains confidential resident information and should not be left where someone could walk off with it. The RN supervisor stated pharmacy delivers medications to the nurses station and that if medication is delivered while staff are serving meals, it should be secured in the narcotic box or medication cart. On Unit 1, the medication room contained expired or out-of-date items, including mineral oil lubricant with an expiration date of 6/21/2025, a box of povidone 10% iodine swab sticks with an expiration date of 11/2025, 3 bottles of wild cherry Pro Stat Liquid with an expiration date of 07/10/2025, and 2 bags of Isosource 1.5 calorie enteral feeding with a use-by date of 09/03/2025. An LPN stated the medication room cabinet had not been checked recently and that expired medications and biologicals should not be in the medication room. The central supply person stated they normally check for expired items on the shelves and periodically check cabinets, but had not checked the cabinets since last week; they also stated they remove expired medications only if found in the cabinets they are restocking. The DON stated all medication rooms are checked and that pharmacy also inspects the medication rooms.
Failure to Provide Adequate Supervision During Mechanical Lift Transfers Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure that residents who required two-person mechanical lift transfers received adequate supervision and assistance, resulting in actual harm to two residents. In the first incident, a resident with diagnoses including heart failure and anxiety, and who was assessed as requiring dependent care from two or more staff for all transfers, was transferred out of bed by a single certified nursing assistant (CNA) using a mechanical lift. During the transfer, the resident fell, sustaining a humerus fracture and facial swelling. The resident reported feeling helpless and scared during the incident. Documentation and interviews confirmed that the CNA performed the transfer alone, contrary to the resident's care plan and facility policy, and did not immediately report the incident to nursing staff. The recreation aide present during a subsequent transfer did not assist and assumed the incident had already been reported. The CNA was later terminated for not following policy. In the second incident, another resident with severe cognitive impairment and hemiparesis, who was also dependent on two or more staff for all activities of daily living, was transferred from bed to chair by a single CNA using a mechanical lift. The CNA attempted the transfer alone after being unable to find assistance, resulting in the resident falling to the floor and sustaining an acute right femur fracture that required surgical intervention. The CNA admitted to transferring the resident alone and not calling for help, despite knowing the requirement for two-person assistance. Another CNA discovered the incident and helped return the resident to bed before notifying the charge nurse. The facility's investigation concluded that the CNA did not follow the resident's plan of care and that there was reasonable cause to believe neglect or mistreatment may have occurred. Both incidents were confirmed through review of medical records, interviews with staff and residents, and facility documentation. The facility's policy required two staff for mechanical lift transfers and immediate reporting of accidents, but these protocols were not followed in either case. The failures resulted in significant injuries to both residents, including fractures and emotional distress, and were attributed to staff actions that disregarded established care plans and facility procedures.
Failure to Timely Report Serious Resident Injuries from Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, exploitation, or mistreatment, specifically in cases where residents sustained serious injuries during transfers with a mechanical lift. According to the facility's own policy and state regulations, such incidents must be reported to the appropriate authorities within two hours if they involve abuse or result in serious bodily injury. However, in two separate cases, the facility did not meet these reporting requirements. In the first case, a resident with diagnoses including heart failure and anxiety, and who required dependent assistance for transfers, fell during a mechanical lift transfer and sustained a left humerus fracture. The incident occurred in the early afternoon, but the injury was not reported to the New York State Department of Health until nearly three days later, after the Regional Director of Nursing reviewed the hospital discharge summary and realized the extent of the injury. Both the Regional Director of Nursing and the Associate Administrator acknowledged awareness of the reporting requirements but could not provide a reason for the delay. In the second case, another resident with severe cognitive impairment and total dependence on staff for activities of daily living fell during a mechanical lift transfer and sustained a right femur fracture. The incident was identified in the early afternoon, and x-ray results confirming the fracture were available later that evening. Despite this, the report to the Department of Health was not submitted until the following morning, more than eight hours after the injury was confirmed. Interviews with nursing and administrative staff revealed uncertainty about reporting responsibilities and a lack of timely action once the injury was identified.
Failure to Update Care Plan After Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was reviewed and revised in response to a significant change in a resident's condition. Specifically, after a resident with diagnoses including heart failure and anxiety fell from a mechanical lift during a transfer—resulting in a humerus fracture and visible swelling—the care plan was not updated to reflect new interventions or address the incident. The resident, who required dependent assistance for transfers and had no prior history of falls, was observed with a sling and swelling, and reported that the fall occurred when only one staff member assisted with the lift transfer, contrary to safe practices. Documentation review revealed that the care plan addressing falls had last been updated prior to the incident and did not include any new interventions following the fall and injury. Interviews with nursing staff and the Director of Nursing confirmed that the care plan was not revised after the event, despite facility policy requiring care plans to be updated as residents' conditions change. The lack of timely review and revision of the care plan following the fall constituted a deficiency in meeting regulatory requirements.
Failure to Ensure Nursing Assessment Before Moving Resident After Fall
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living and required two or more staff for mechanical lift transfers, was not properly assessed and evaluated by a nurse before being moved after a fall. The facility's policy required that accident victims not be moved until examined by a nurse, but this protocol was not followed. Instead, after the resident fell during a mechanical lift transfer performed by a single certified nursing assistant (CNA) without the required second staff member, the resident was assisted from the floor back to bed by two CNAs without prior nursing assessment. The incident began when a CNA attempted to transfer the resident alone using a mechanical lift, contrary to the resident's care plan and facility policy, which mandated two staff for such transfers. The CNA reported being unable to find assistance and proceeded alone, resulting in the resident falling to the floor. Another CNA entered the room, observed the resident on the floor, and helped move the resident back to bed before notifying the charge nurse. Both CNAs involved did not follow the protocol to summon help or ensure a nurse assessed the resident prior to moving them. Interviews confirmed that the nurse manager and LPN were not informed of the incident until after the resident had been placed back in bed. Upon assessment, the resident exhibited decreased passive range of motion and pain in the right lower extremity, and subsequent investigation revealed a right hip fracture requiring surgical intervention. The facility's investigation concluded that the care plan and accident protocol were not followed, and there was no documentation of a nursing assessment prior to moving the resident after the fall.
Failure to Apply Prescribed ROM Devices for Resident with Contractures
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and hemiplegia was not provided with prescribed range of motion (ROM) devices, specifically a right knee and elbow brace, as outlined in their care plan. The resident, who was dependent on staff for all activities of daily living and had contractures in both upper and lower extremities, was observed multiple times without the required devices in place. The care plan and Kardex specified that the right knee and elbow braces should be worn at all times except during skin checks and hygiene care, but these instructions were not consistently visible or communicated to the staff responsible for the resident's care. Interviews with multiple Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) revealed that they were unaware of the need to apply the braces and had not seen or applied them during their care of the resident. The CNAs also reported that the devices were not visible in their electronic medical record task lists, and they were unsure how to access such instructions. The charge nurse and other supervisory staff were also unaware that the CNAs could not view or implement the care plan instructions regarding the devices. Further investigation showed that the devices were found unused in the resident's closet, and there was no documentation in the CNA task records indicating that the braces had been applied over a period of several months. The Rehabilitation Director confirmed that the devices had been issued and were to be applied at all times except for care, but audits to ensure compliance had not been conducted recently. The Director of Nursing and Assistant Director of Nursing stated that staff were expected to follow the care plan, but they were not aware that the devices were not being used as intended.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,315 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brooklyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brooklyn Gardens Nursing & Rehabilitation Center | 0.4 mi | ★★★★★ | 4 | 0 |
| Crown Heights Center For Nursing And Rehabilitatio | 0.6 mi | ★★★★★ | 5 | 0 |
| Rutland Nursing Home, Inc | 1.1 mi | ★★★★★ | 1 | 0 |
| Dr Susan Smith Mckinney Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| Schulman And Schachne Inst For Nursing & Rehab | 1.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Brooklyn Center For Rehabilitation And Residential.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.