Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Concord Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that residents’ right to a safe, clean, and homelike environment was not maintained on several units. On multiple floors, strong urine odors were present, resident rooms and bathrooms had brown and black staining on toilets, tiles, walls, and sinks, and equipment such as oxygen concentrators and GT poles were dusty or coated with residue while in use. Common areas, including nurses’ stations, hallways, dining rooms, and shower rooms, showed dark greasy stains, cracked or blackened tiles, rusted fixtures, peeling wallpaper, and visible dirt and debris, with some shower stalls lacking adequately hot water. Housekeeping and maintenance staff reported unclear or inconsistent cleaning responsibilities, reduced staffing, lack of scheduled cleaning for specific items, and acknowledged that floors, tiles, and walls were dirty and in need of replacement, while leadership acknowledged the poor overall condition of the environment.
The facility did not maintain two of three elevators in safe working condition for several months, resulting in restricted resident movement and delays in services. Despite "Not Working" signs on two elevators, one was still used and skipped a floor. Multiple residents reported repeated complaints at council meetings about broken elevators, difficulty leaving their units, and food arriving cold because the service elevator used for meal transport was out of service, requiring use of an alternate elevator. The Director of Recreation acknowledged delays in moving residents and needing to wait or page for an elevator, while the Director of Maintenance and the Administrator confirmed that two elevators were out of service for an extended period and that complaints had been received.
A resident with severe cognitive impairment and high elopement risk exited the facility undetected despite wearing a wander alert device and being on enhanced monitoring. Staff failed to respond appropriately to an activated door alarm, did not conduct a full head count, and relied on incomplete checks and miscommunication, resulting in the resident being found and returned by police after leaving through a staircase and a gap in the fence.
The facility failed to maintain infection control practices, as a resident's urinary drainage bag was repeatedly observed on the floor, contrary to policy. Additionally, an RN did not perform hand hygiene between glove changes during a gastrostomy dressing change for a resident dependent on enteral feeding. The facility's Legionella Water Management Program also lacked a component specifying acceptable pathogen levels.
A resident with severe cognitive impairment was observed with a mitten on their right hand, used as a restraint without proper assessment, care planning, or documentation. Facility staff, including a CNA and RN, were unaware of the necessary procedures and documentation for restraint use, leading to the inappropriate application of the mitten.
A survey found that a resident's medications were left unattended on a medication cart in an LTC facility. The medications, belonging to a resident with severe cognitive impairment, were unsecured for over 15 minutes. Interviews with staff, including an LPN and the DON, confirmed that the medications should have been locked, as per facility policy.
The facility did not post notices about the availability of survey results in accessible areas, as required by policy. Observations showed the notice was hidden in the lobby, and no notices were in resident units. Residents were unaware of where to find the survey results, confirmed during a Resident Council Meeting. The DON and Administrator were unaware of the issue.
A resident with severe cognitive impairment and multiple diagnoses, including Dementia and Heart Disease, was observed with toe discolorations. Despite a doctor's order for an Arterial Doppler Study, the care plan for Impaired Skin Integrity was not updated to reflect this condition. The facility's policy requires ongoing assessment and revision of care plans, but the responsible nurse was unaware of the condition, leading to a deficiency citation.
A facility failed to document a medical assessment in a resident's record, despite the resident having discoloration on their toes and a history of dementia, heart disease, and atrial fibrillation. The Primary Medical Doctor assessed the condition and instructed an LPN to monitor the foot and order an Arterial Doppler Study, but the assessment was not recorded. This oversight violated the facility's documentation policy and regulatory requirements.
Widespread Environmental Uncleanliness and Disrepair Across Multiple Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on multiple resident units, contrary to its own maintenance and environmental cleaning policies. Surveyors repeatedly observed strong urine odors, stained and soiled surfaces, and disrepair across Units 2, 3, and 4. On the 2nd floor, there was a noticeable urine odor upon exiting the elevator, and a resident room had a tarnished door frame with brown staining, brown substance on the wall, brown stains on the toilet, dirty brown tiles behind the toilet, foul‑smelling hand towels, and a dripping sink faucet. The 2nd floor shower room and dirty linen cart room contained brown substances on walls and floors, a dirty linen bag on the floor, a hairbrush and comb on the shower floor, and underwear left on a wheelchair. Additional 2nd floor observations included dusty oxygen equipment with white residue, undated tubing in use on a resident’s tracheostomy, a GT pole with brown residue and buildup at the base, blackened flooring at room entrances and around furniture, white splash marks on walls, dirty baseboards, and blackened tiles. The 2nd floor nurses’ station had black floor tiles, dirty and rusted oxygen tank holders, and a buildup of dirt and dust under the desk around wires. On the 3rd floor, surveyors observed environmental uncleanliness and disrepair in common areas and resident spaces. The nurses’ station had a black chair covered with paper as a barrier from dirt or residue, another black chair missing an armrest, old food and dark‑stained floor tiles under the desk, a stained wall behind the station, a cabinet door missing handles and appearing broken, and a resident refrigerator with brown rusted stains on the exterior. The 3rd floor resident shower room had a musty, stale odor, black‑stained floor tiles at the entrance, brown stains on ceiling tiles and flooring, and white and brown substances on the floor of one shower stall. In a resident room, the sink edges had brown substance and the floor was sticky with areas of dirt; another room contained a ripped chair and dirty bedside table tray, and peeling wallpaper was noted near a room. Both radiators in the 3rd floor shower room were rusted, and floor tiles leading to the shower stall had brown‑colored substance around the edges. Hallways and the dining room on this unit had dark brown stains, dark greasy stains in corners and on baseboards, and multiple cracked tiles. During a tour of two shower stalls with maintenance staff, the hot water in both stalls remained cool to the touch despite running for several minutes, with thermometer readings in the high 70s to low 80s °F, and one shower head was leaking. On the 4th floor, surveyors noted brown stains on floors, yellow stains in dining room and hallway floors, and dark, greasy, dirt‑filled stains in the corners of hallways and the day room, as well as brown stains at the entrance to the garbage holding station. Across the 2nd floor vent unit, there were tiles with visible brown stains, brown and white discoloration and white splatter on hallway wallpaper between guardrails, peeling wallpaper, and a fire extinguisher case with brown discoloration and a peeling directional sign. Interviews with housekeeping and maintenance staff revealed inconsistent cleaning responsibilities, lack of clear schedules for cleaning specific items such as oxygen concentrators and GT poles, and acknowledgment that floors, tiles, and walls were dirty and in need of replacement. Staff reported decreased housekeeping staffing, uncertainty about who was responsible for certain areas (such as hallways and dining areas), and that some areas were only cleaned when specifically instructed. The Director of Housekeeping/Maintenance stated they rely on staff to report needed repairs and that they try to address items as they are identified, while the Administrator acknowledged the poor condition of the facility without providing an explanation, confirming that the environment did not meet regulatory requirements for cleanliness and maintenance. The facility’s written policies required that maintenance services keep the building in good repair and free from hazards, and that environmental surfaces be cleaned and disinfected regularly and when visibly soiled, in accordance with CDC and OSHA standards. However, the observations documented by surveyors showed widespread failure to follow these policies, including persistent urine odors, visible dirt and staining on floors, walls, and equipment, cracked and peeling surfaces, rusted fixtures, and inadequate hot water in resident shower areas. Staff interviews further demonstrated gaps in implementation of these policies, with staff describing ad hoc cleaning based on supervisory direction rather than a structured schedule, and multiple staff acknowledging that the building and flooring needed repairs. These combined observations and statements formed the basis of the deficiency under 10 NYCRR 415.5(h)(2) and 10 NYCRR 415.5(h)(4) for not honoring residents’ rights to a safe, clean, comfortable, and homelike environment.
Failure to Maintain Elevators in Safe Working Condition
Penalty
Summary
The facility failed to maintain essential elevator equipment in safe working condition, affecting two of three elevators (Elevator #2 and #3). Observations over several days showed "Not Working" signage posted on both elevators, yet Elevator #2 was still being used and was noted to skip the third floor. Resident council meeting notes revealed that residents reported these two elevators had been broken for several months and that they had raised this issue repeatedly at prior resident council meetings without resolution. Residents reported that the malfunctioning elevators restricted their movement within the building and interfered with normal access to other areas. Residents also reported that food was arriving cold to their units because Elevator #3, which is mainly used to transport food to all units, was broken, requiring use of an alternate elevator. One resident stated they often could not leave their unit due to the broken elevators. The Director of Recreation acknowledged awareness of the broken elevator and described delays in moving residents around the facility, including having to wait or page for an elevator when needed. The Director of Maintenance confirmed that the facility has three elevators, with two for passengers and one for moving items, and that Elevators #2 and #3 were out of service and undergoing refurbishment. The Administrator confirmed that Elevators #2 and #3 had been broken and out of service for a few months and acknowledged receiving complaints from residents and families about the elevator problems.
Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition and a high risk for elopement exited the facility undetected by staff. The resident, who had diagnoses including Non-Traumatic Brain Dysfunction and Alzheimer's Disease, was wearing a wander alert device and was supposed to be monitored every thirty minutes. Despite these interventions, the resident was last documented as seen at 11:00 PM, but managed to leave the building at 12:24 AM. The resident was later found and returned to the facility by police officers at 12:40 AM, having exited through a staircase and a gap in the fence behind the building. Staff failed to respond appropriately to the activated door alarm. Multiple staff interviews revealed that alarms were either not heard, were faint, or were silenced without a thorough investigation. One LPN heard the alarm but only checked the area for a resident known to wander, rather than conducting a full head count or searching all possible exit routes. Security staff also failed to physically check the exit doors after the alarm was triggered, relying instead on surveillance cameras and resetting the alarm remotely. Additionally, a CNA mistook pillows in the resident's bed for the resident being present, further delaying the realization that the resident was missing. The facility's policies required enhanced monitoring, functioning wander alert devices, and prompt response to alarms, but these were not effectively implemented. Staff did not conduct a head count or search all areas after the alarm was triggered, and communication lapses occurred between staff members regarding the alarm and the resident's whereabouts. These failures allowed the resident to leave the facility without detection, resulting in an elopement event.
Infection Control Deficiencies in Urinary Catheter Care, Hand Hygiene, and Water Management
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple observations of a resident's urinary drainage bag being placed on the floor. Resident #27, who had a suprapubic catheter due to neurogenic bladder and other urinary issues, was observed on several occasions with their urinary drainage bag touching the floor. Despite the facility's policy and staff education on catheter care, the bag was repeatedly found on the floor, indicating a lapse in adherence to infection control protocols by the staff, including a Certified Nursing Assistant and a Registered Nurse Supervisor. Another deficiency was noted when Registered Nurse #2 did not perform hand hygiene between glove changes during a gastrostomy dressing change for Resident #80. This resident, who had a gastrostomy and was dependent on enteral feeding, was at risk due to the nurse's failure to wash hands between removing and donning gloves. The facility's hand hygiene policy, which aligns with CDC recommendations, was not followed, as confirmed by interviews with the nurse and the Director of Nursing. Additionally, the facility's Legionella Water Management Program was found lacking a critical component specifying acceptable pathogen levels. This omission was identified during a review of the water management plan, and the Administrator acknowledged the need to include all required components. These deficiencies highlight significant gaps in the facility's infection control practices, potentially compromising resident safety.
Inappropriate Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a mitten on the resident's right hand without proper assessment, care planning, or documentation. The resident, who had diagnoses including Other Specified Disorders of Brain, Vascular Dementia, and Non-traumatic Intracerebral Hemorrhage, was observed with a mitten on their right hand during multiple observations. Despite the facility's policy promoting a restraint-free environment, there was no documented evidence of an appropriate assessment or care plan prior to the application of the mitten, nor was there any documented monitoring while the mitten was in use. Interviews with facility staff revealed a lack of awareness and communication regarding the use of the mitten as a restraint. A Certified Nursing Assistant stated they applied the mitten based on instructions from a charge nurse, but there were no instructions in the task list to do so. The unit supervisor assumed there was a restraint assessment and physician's order, while the Director of Nursing was unaware of the mitten's use. The Nurse Practitioner confirmed they did not order the mitten, and the Director of Rehabilitation noted the resident could not remove the mitten independently. This lack of documentation and communication led to the inappropriate use of a physical restraint on the resident.
Medication Storage Deficiency
Penalty
Summary
During a recertification survey, it was observed that the facility failed to store medications in accordance with accepted professional principles. On the 4th floor, medications belonging to a resident with diagnoses including Essential Hypertension, Epilepsy, Gastroesophageal Reflux Disease, and Cardiomyopathy were left unattended on top of a medication cart. The resident had severely impaired cognition, as documented in their Minimum Data Set assessment. The medications, which included Losartan, Spironolactone, Famotidine, and Levetiracetam, were left unsecured for over 15 minutes until a state surveyor intervened. Interviews with facility staff, including an LPN, a Registered Nurse Supervisor, and the Director of Nursing Services, confirmed that the medications were not stored properly. The LPN admitted that the medications were older blister packs intended for return to the pharmacy and acknowledged that they should have been secured under lock and key. Both the Registered Nurse Supervisor and the Director of Nursing Services stated that medications should not be left unsecured on top of the cart, emphasizing that all medications should be locked to ensure safety.
Failure to Post Survey Results Notices in Accessible Areas
Penalty
Summary
The facility failed to ensure that notices regarding the availability of survey results were posted in prominent and accessible areas, as required by their policy. During the recertification survey, it was observed that the notice was placed in the lobby entrance next to the security desk, behind a standing sign, making it not visible to residents or visitors. Additionally, there were no notices posted in resident units to inform residents, family members, or legal representatives about where to find the survey results. Interviews conducted during the survey revealed that residents were unaware of where to find the survey results, as confirmed by multiple residents during a Resident Council Meeting. The Director of Nursing acknowledged the absence of notices in resident units and stated that the notice was only posted in the lobby. The Administrator was also unaware of the lack of notices in resident units and mentioned that the availability of survey results is discussed in Resident Council meetings.
Failure to Update Care Plan for Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team, as required by their policy. This deficiency was identified during an abbreviated survey, where it was found that a resident's care plan was not updated to reflect a new condition. The resident, who has diagnoses including Dementia, Atherosclerotic Heart Disease, and Chronic Atrial Fibrillation, was observed with discolorations on the toes of their left lower extremity. Despite the medical doctor being notified and ordering an Arterial Doppler Study, the care plan for risk of Impaired Skin Integrity was not updated to include this new information. The facility's policy requires that care plans be comprehensive, person-centered, and revised as residents' conditions change. However, the care plan for the resident's Alteration in Comfort due to Peripheral Vascular Disease was last revised before the discoloration was noted, and the care plan for Impaired Skin Integrity had not been updated since March. The Regional Registered Nurse, responsible for updating care plans, was unaware of the discolorations and thus did not update the care plan until after the surveyor's presence in the facility. This oversight led to the deficiency being cited.
Failure to Document Medical Assessment in Resident's Record
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately reflected their current condition, as required by professional standards. This deficiency was identified during an abbreviated survey, where it was found that a medical assessment conducted by the Primary Medical Doctor was not documented in the resident's medical record. The resident in question had a history of dementia, atherosclerotic heart disease, and chronic atrial fibrillation, and was reported to have discoloration on the toes of their left foot. Despite the Primary Medical Doctor assessing the resident's condition and instructing a Licensed Practical Nurse to monitor the foot and order an Arterial Doppler Study, the assessment was not recorded in the medical record. The facility's policy on charting and documentation, which mandates that all services and changes in a resident's condition be documented, was not followed. The Director of Nursing acknowledged that the staff member who informed the Primary Medical Doctor and received the order for the Arterial Doppler Study should have documented the event in the resident's medical record. This oversight resulted in a failure to maintain accurate and complete medical records, as required by 10 NYCRR 415.22(a)(1-4).
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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) |
|---|---|---|---|---|
| Downtown Brooklyn Nursing & Rehabilitation Center | 0.9 mi | — | 0 | 0 |
| Crown Heights Center For Nursing And Rehab | 1.1 mi | — | 5 | 0 |
| Brooklyn Gardens Nursing & Rehabilitation Center | 1.2 mi | — | 4 | 0 |
| Bedford Center For Nursing And Rehabilitation | 1.2 mi | — | 0 | 0 |
| New Carlton Rehab And Nursing Center, L L C | 1.3 mi | — | 0 | 0 |
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