Inspection Reports for
Boro Park Center for Rehabilitation and Healthcare
4915 10th Ave, Brooklyn, NY, 11219
Back to Facility ProfileInspection Report — May 6, 2024
Annual Inspection
Citations: 6
Date: May 6, 2024
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements and facility policies.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, improper use of physical restraints without orders, inadequate assistance with activities of daily living, insufficient pressure ulcer care, expired medications and intravenous fluids storage issues, and improper food storage with expired and unlabeled items.
Citations (6)
F 0577: The facility did not ensure survey results were posted in a place readily accessible to residents and visitors without having to ask for them.
F 0604: Resident #151 was physically restrained by wrapping their right hand with a towel without a current physician order or care plan.
F 0677: Resident #263 did not receive timely bladder/bowel care, resulting in inadequate assistance with activities of daily living.
F 0686: Residents #523 and #380 did not receive appropriate pressure ulcer care; Resident #523 was observed without ordered heel boots and Resident #380 had an uncovered Stage 3 sacral pressure ulcer exposed to loose stool.
F 0761: The facility stored expired intravenous fluids in two medication storage areas, violating medication storage standards.
F 0812: The facility stored expired enteral feeding and unlabeled, degraded, and expired food items in nourishment rooms and refrigerators.
Report Facts
Residents reviewed: 38
Expired intravenous fluid bags: 25
Expired enteral feeding cartons: 21
Expired yogurt cups: 2
Expired ice cream cups: multiple
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Applied mitten or towel restraint to Resident #151 without order | |
| Registered Nurse #1 | Unit Manager | Unaware of restraint use on Resident #151 and continence care delays for Resident #263 |
| Certified Nursing Assistant #7 | Reported Resident #523's refusal to wear heel boots not communicated to Charge Nurse | |
| Licensed Practical Nurse #3 | Responsible for medication rounds and ensuring pressure ulcer prevention interventions | |
| Registered Nurse #4 | Unit manager supervising nursing staff and care | |
| Director of Nursing | Director of Nursing Services | Oversight of pressure ulcer prevention and medication storage compliance |
| Licensed Practical Nurse #8 | Observed expired intravenous fluids in medication room | |
| Registered Nurse #5 | Unit Manager for 2 East | Checked medication room daily and acknowledged expired intravenous fluids |
| Assistant Food Service Director | Conducted kitchen tour and acknowledged expired enteral feeding | |
| Dietary Supervisor | Responsible for storeroom and rotation of food items | |
| Registered Nurse #3 | Nurse Manager | Observed spoiled and expired food in 5th floor pantry refrigerator |
| Housekeeping Supervisor | Explained why some expired food items were not discarded from refrigerator |
Inspection Report — May 6, 2024
Complaint Investigation
Citations: 13
Date: May 6, 2024
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2024 with citation and enforcement history.
Complaint Details
The facility received 61 complaints with 6 on-site inspections conducted. No citations resulted from these complaints during the reporting period.
Findings
Across 5 inspections, 4 had no citations while 1 inspection resulted in 13 citations including standard health and life safety code violations. The facility had 61 complaints with 6 on-site inspections and 4 enforcement actions totaling $50,000 in fines.
Citations (13)
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents was deficient.
Standard Health Citation — quality of care: Department Criminal History Review was deficient.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary was deficient.
Standard Health Citation — quality of care: Infection Control was deficient.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals was deficient.
Standard Health Citation — quality of care: Right To Be Free From Physical Restraints was deficient.
Standard Health Citation — quality of care: Right To Survey Results/advocate Agency Info was deficient.
Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer was deficient.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Other was deficient.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Out Of Service was deficient.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress was deficient.
Life Safety Code Citation — NFPA requirements: Organization And Administration was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient.
Report Facts
Inspections on page: 5
Total citations: 13
Inspections with violations: 1
Inspections without violations: 4
Total complaints: 61
On-site complaint inspections: 6
Total enforcement actions: 4
Total fines: 50000
Inspection Report — Apr 21, 2022
Annual Inspection
Citations: 11
Date: Apr 21, 2022
Visit Reason
The inspection was a Recertification survey conducted from 4/14/22 to 4/21/22 to assess compliance with federal regulations for nursing home certification.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare non-coverage notices, incomplete significant change assessments for hospice residents, late submission of MDS data, incomplete care plans for residents with diabetes and anticoagulant therapy, failure to invite residents to care plan meetings, medication administration errors, expired medications in emergency boxes, improper food storage and temperature control, lack of behavioral monitoring for residents on antipsychotics, and failure to maintain infection control practices such as mask use during recreational activities.
Citations (11)
F 0582: Facility failed to provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage timely to Medicare beneficiaries, affecting 1 of 3 residents reviewed.
F 0637: Facility did not complete a Significant Change in Status Assessment following the start of hospice services for 1 of 1 resident reviewed.
F 0640: Facility failed to electronically transmit accurate and complete MDS data within 14 days for 1 of 2 residents reviewed.
F 0656: Facility did not develop comprehensive care plans with measurable objectives for residents with diabetes and anticoagulant medication, affecting 2 of 9 residents reviewed.
F 0657: Facility did not ensure residents were offered opportunity to participate in care plan meetings; 1 of 2 residents reviewed was not invited to meetings.
F 0658: Facility failed to ensure medication administration met professional standards; RN pre-poured medication and did not observe resident taking all medications for 1 of 37 residents observed.
F 0755: Facility did not ensure pharmaceutical services met resident needs; emergency medication box with expired medications was found in a medication storage room.
F 0758: Facility did not ensure a resident's drug regimen was free of unnecessary medications; no documented behavioral monitoring for a resident with dementia prescribed antipsychotics.
F 0759: Facility medication error rate exceeded 5%; RN administered pre-poured medication and did not observe resident taking all prescribed medications.
F 0812: Facility failed to ensure food was stored, prepared, and served in accordance with professional standards; expired cottage cheese found and hot foods on tray line were below safe holding temperatures.
F 0880: Facility did not maintain infection control practices; recreational staff observed singing without masks in dining room in violation of facility policy.
Report Facts
Residents reviewed: 38
Medication error rate: 8.11
Expired cottage cheese quantity: 28
Hot food temperatures: 148
Hot food temperatures: 150
Hot food temperatures: 100
Hot food temperatures: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration error for Resident #295 |
| Nurse Manager #3 | Nurse Manager | Interviewed regarding care plan deficiencies for residents with diabetes and anticoagulant therapy |
| Nurse Manager #2 | Nurse Manager | Interviewed regarding behavioral observations for Resident #402 |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding Resident #402 behavior and family involvement |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding Resident #402 behavior and medication refusal |
| Director of Nursing | DON | Interviewed regarding medication administration policies and expired medication boxes |
| Director of Recreation | DOR | Interviewed regarding mask use by recreational staff |
| Infection Preventionist | Interviewed regarding infection control practices | |
| Food Service Supervisor #1 | FSS | Interviewed regarding expired food and food temperature monitoring |
| Assistant Director of Food Services | ADFS | Interviewed regarding expired food handling |
| Nurse Practitioner | NP | Interviewed regarding psychotropic medication management for Resident #402 |
| Medical Director | MD | Interviewed regarding psychotropic medication management for Resident #402 |
Inspection Report — Jul 26, 2019
Renewal
Citations: 1
Date: Jul 26, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with food safety and sanitation standards in the facility's kitchen equipment.
Findings
The survey found that multiple pieces of food slicing equipment, including the meat slicer and Robot coupe CL50 quarter dicer blade, were not properly cleaned and contained debris. The facility acknowledged lapses in cleaning supervision and purchased new equipment to replace those with debris.
Citations (1)
F 0812: The facility failed to ensure all food slicing equipment was maintained in a clean sanitary manner, with observed debris on the meat slicer and dicer blades after cleaning.
Report Facts
Years worked: 15
Years worked: 5
Years worked: 15
Date of survey completion: Jul 26, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding cleaning procedures and acknowledged lapses in supervision | |
| Dietary Supervisor | Observed cleaning practices and noted debris on equipment | |
| Dietary Aide (DA#1) | Described cleaning procedures and limitations in equipment disassembly | |
| Porter (P#1) | Responsible for disassembling and cleaning meat slicer during shift | |
| Porter (P#2) | Confirmed cleaning procedures and verified equipment cleanliness |
Viewing
Loading inspection reports...
