Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Cobble Hill Health Center Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment had an unwitnessed fall and was later found to have an acute subcapital hip fracture after initially negative x-rays of the leg, ankle, and knee. The ADON, DON, and Administrator stated the event was not reported to the State because they believed the fracture was related to the fall and not an injury of unknown origin, despite the roommate not knowing how the fall occurred.
Care Plan Not Revised for Resident With Actual Pain: A resident with osteoarthritis and back pain developed significant left knee pain requiring multiple pain interventions, including PRN meds, a lidocaine patch, a STAT NSAID dose, and an x-ray. Despite documented pain ratings up to 10/10 and a pain mgmt consult noting acute pain and medication adjustments, the care plan remained a potential pain plan and was not updated to reflect the resident’s actual pain, location, goals, or interventions; RN, UM, and DON interviews confirmed the lapse.
A resident with a history of osteoarthritis, osteoporosis, and dementia fell and sustained a right femur fracture. The RN on duty failed to report the fall or document an assessment, leading to a delay in treatment. The incident was only discovered during an investigation two days later, revealing neglect and non-compliance with facility policies.
The facility failed to ensure food was prepared and served in accordance with professional standards, as expired food items were found in the kitchen refrigerators. Despite policies and procedures in place, the dietary staff overlooked expired items during their checks.
The facility failed to report a resident-to-resident altercation to the New York State Department of Health within the required 2-hour timeframe. Two residents, both with dementia, were involved in an incident where one resident grabbed and hit the other. The incident was reported to the nursing staff on the same day but was not reported to the state until the following day.
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter, omitting necessary interventions for monitoring urinary output and providing Foley catheter care, despite physician orders and facility policy requirements.
A resident with Alzheimer's Disease and Anemia did not have bilateral hand rolls applied as per the Physician's Order, leading to a deficiency. Observations and interviews confirmed the lack of adherence to the order, which required the hand rolls to be applied during the day and removed every shift for skin inspection.
The facility failed to ensure a resident requiring dialysis services received such services consistent with professional standards of practice, as there was no Physician's Order for the resident to receive hemodialysis treatment. Despite documentation of pre and post dialysis monitoring, the necessary Physician's Order was missing.
Failure to Report Unwitnessed Fall With Subsequent Hip Fracture
Penalty
Summary
The facility failed to ensure that an alleged injury of unknown source involving Resident #370 was reported immediately, and no later than 2 hours after the allegation when serious bodily injury was involved, to the State Survey Agency. Resident #370 had diagnoses including atrial fibrillation, coronary artery disease, and heart failure, and the admission MDS documented severe cognitive impairment with substantial to maximal assistance needed for most ADLs. On 03/20/2026, the resident had an unwitnessed fall after the roommate reported the resident was on the floor. The resident was evaluated by a physician with no treatment orders, and later that evening x-rays of the left leg, ankle, and knee showed no acute abnormalities. The facility’s investigative summary documented that on 03/23/2026 the resident developed increased pain and moaning when the left leg was touched, prompting an x-ray of the left hip that revealed an acute subcapital fracture. The Assistant DON, DON, and Administrator stated during interviews that the incident was not reported to the New York State Department of Health because they believed the fracture was related to the fall and was not suspicious or an injury of unknown origin. The roommate had observed the resident on the floor but did not know how the fall occurred, and the resident’s severe cognitive impairment prevented the resident from providing information about the circumstances.
Care Plan Not Revised for Resident With Actual Pain
Penalty
Summary
The facility failed to ensure that a resident’s comprehensive care plan was reviewed and revised after a significant change in condition and ongoing pain management interventions. The resident had diagnoses including osteoarthritis, vertebral low back pain, and hypertension, and the quarterly MDS documented intact cognition, assistance with ADLs, and no pain management. A physician’s order included acetaminophen as needed for chronic pain, a lidocaine patch to the left knee, and gabapentin for pain. Nursing documentation showed the resident reported left knee pain rated 6/10, then worsening pain rated 10/10 despite Tylenol, prompting notification of the physician and STAT orders for ibuprofen and a left knee x-ray. A pain management consultation documented acute intermittent left knee pain aggravated by ADLs and requiring multiple pain management interventions, including medication adjustments, with goals to reduce pain and improve function, endurance, and ROM. However, the resident’s care plan remained a “Potential Pain” plan last evaluated earlier and was not revised to reflect actual pain, the left knee location, the stated goals, or the ongoing interventions. Staff interviews confirmed that the resident should have had an actual pain care plan, that nursing staff were responsible for updating it, and that the Unit Manager and DON could not explain why the care plan had not been updated.
Failure to Report and Document Resident Fall
Penalty
Summary
The facility failed to ensure that the services provided met professional standards of quality, as evidenced by the handling of a fall incident involving a resident. On the night shift, a resident was found on the floormat and was picked up and put back into bed by an RN without reporting the fall or documenting an assessment. The resident was later found to have sustained an acute nondisplaced right femur intertrochanteric fracture, which was not reported until two days later during an interview with the RN involved. The facility's investigation revealed that the RN did not report the fall because it was close to the end of their shift, and there was no documented evidence of an assessment being conducted at the time of the incident. The resident involved had a medical history including osteoarthritis, osteoporosis, and dementia, and required extensive assistance for mobility. Following the incident, the resident exhibited signs of pain and bruising, which were documented by other nursing staff. An x-ray was ordered, and the results confirmed the fracture. The resident was subsequently transferred to the hospital for further evaluation and treatment. Interviews with various staff members, including the CNA who assisted the RN and the nursing supervisor, confirmed that the fall was not reported or documented as required by the facility's policies. The Director of Nursing conducted an investigation and concluded that there was evidence of neglect, as the RN failed to report the incident and did not follow the proper procedures for assessing and documenting the resident's condition after the fall.
Expired Food Items Found in Kitchen Refrigerators
Penalty
Summary
The facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. During a kitchen observation, expired food was found in the kitchen refrigerators. Specifically, two 5 lb tubs of egg salad and two 5 lb plastic containers of egg salad with use-by dates that had passed were found in Refrigerator #1. Additionally, two wrapped whole baked hams with expired use-by dates were found in Refrigerator #3. This was contrary to the facility's policy, which required all food items to be labeled with the date received and utilized using the First In, First Out process, with expired items being discarded immediately. Interviews with the dietary staff revealed that food deliveries were received three times a week, and items were supposed to be rotated using the First In, First Out method. However, the Dietary Aide admitted to forgetting to check for expired items, and the Food Service Manager, who was responsible for checking the refrigerators twice daily, also overlooked the expired items. The Food Service Director confirmed that all kitchen staff were instructed to check for expired foods and to use the First In, First Out method, but the expired food items in the refrigerators were missed during their daily walk-throughs.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility did not ensure allegations involving abuse were reported to the New York State Department of Health within 2 hours of occurrence. This deficiency was evident for two residents involved in a resident-to-resident altercation. Specifically, Resident #246 and Resident #210, both diagnosed with hypertension and dementia, were involved in an incident where Resident #210 grabbed and hit Resident #246. The incident was witnessed by Resident #246's son and reported to the nursing staff on the same day. However, the facility did not report the incident to the New York State Department of Health within the required 2-hour timeframe, instead reporting it the following day. The facility's policy requires the Administrator and Director of Nursing to report all alleged violations of abuse, neglect, or misappropriation promptly. During interviews, the Director of Nursing and the Administrator stated that the facility typically reports such incidents as soon as possible. However, in this case, the Director of Nursing mentioned that they conducted interviews and gathered statements before reporting the incident, which delayed the reporting process. The Administrator also noted that the incident was reported the same day, but documentation showed it was reported the next day, thus not meeting the 2-hour reporting requirement.
Deficiency in Comprehensive Care Plan for Urinary Catheter
Penalty
Summary
The facility did not ensure a person-centered Comprehensive Care Plan was developed and implemented to meet a resident's needs. Specifically, for one resident with an indwelling urinary catheter, the care plan lacked interventions to address monitoring urinary output and providing Foley catheter care. The resident had diagnoses of Benign Prostate Hypertrophy and Diabetes Mellitus and was cognitively intact. Despite physician orders for urinary output monitoring and Foley catheter care every shift, the care plan only included interventions related to urinary incontinence and maintaining dignity, without addressing the specific needs for catheter care. Interviews with facility staff, including a Registered Nurse and the Assistant Director of Nursing, confirmed that the care plan should have included goals and interventions for Foley catheter care. The facility's policy on Comprehensive Care Planning required measurable goals and timetables to meet the resident's medical, nursing, and psychosocial needs, which was not adhered to in this case.
Failure to Apply Bilateral Hand Rolls as Ordered
Penalty
Summary
The facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Specifically, Resident #243, who had diagnoses of Alzheimer's Disease and Anemia, did not have bilateral hand rolls in place according to the Physician's Order. The Minimum Data Set 3.0 assessment documented that Resident #243 was severely cognitively impaired, had functional limitations on their left upper extremity, and required assistance with activities of daily living. Observations on 2/8/2024 and 2/15/2024 revealed that the resident either had no hand rolls or only one hand roll in place, contrary to the Physician's Order dated 3/29/2022 and renewed on 01/30/2024, which required bilateral hand rolls to be applied during the day and removed every shift for skin inspection. There was no documented evidence that the hand rolls were applied as ordered. Interviews with Certified Nursing Assistant #7, the Occupational Therapist, and the Assistant Director of Nursing confirmed that Resident #243 required bilateral hand rolls to help extend their hand and fingers and to prevent further hand contractures. The facility policy titled Activities of Daily Living Care Guidelines dated 10/2023 also documented that the Certified Nursing Assistant would apply splints, braces, and assistive devices as directed. However, the facility failed to adhere to these guidelines and the Physician's Order, resulting in the deficiency.
Lack of Physician's Order for Hemodialysis Treatment
Penalty
Summary
The facility did not ensure that a resident requiring dialysis services received such services consistent with professional standards of practice. Specifically, there was no Physician's Order for Resident #645 to receive hemodialysis treatment. Resident #645, who was admitted with diagnoses of Hypertension, Diabetes, and Hyperlipidemia, had a Comprehensive Care Plan indicating he received dialysis treatment at a dialysis center. Despite documentation of pre and post dialysis monitoring and vital signs on multiple dates, there was no documented evidence of a Physician's Order for the hemodialysis treatment. Interviews with a Registered Nurse and the Medical Director confirmed the absence of the necessary Physician's Order for the resident's hemodialysis treatment.
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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.
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Nursing homes near Brooklyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hopkins Center For Rehabilitation And Healthcare | 0.5 mi | ★★★★★ | 0 | 0 |
| Oxford Nursing Home | 0.9 mi | ★★★★★ | 4 | 0 |
| The Phoenix Rehabilitation And Nursing Center | 1 mi | ★★★★★ | 0 | 0 |
| New Carlton Rehab And Nursing Center, Llc | 1.4 mi | ★★★★★ | 0 | 0 |
| New Gouverneur Hospital S N F | 1.7 mi | ★★★★★ | 0 | 0 |
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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.