Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as a Recertification Survey from 08/21/2024 to 08/28/2024 to assess compliance with professional standards related to food service safety and infection prevention and control practices.
Findings
The facility was found deficient in food handling and storage practices, including staff handling resident food with bare hands and expired or undated food items in the kitchen refrigerator. Additionally, infection prevention practices were inadequate as enhanced barrier precautions were not maintained during wound care for a resident with a chronic wound.
Deficiencies (3)
Staff was observed handling resident's food with bare hands during dining observation.
The kitchen walk-in refrigerator contained expired and undated food items.
Enhanced Barrier Precautions were not maintained during wound care for Resident #90; Licensed Practical Nurse performed wound care without wearing a gown and signage was removed.
Report Facts
Expired food items: 7
Units with food handling issue: 1
Residents reviewed for pressure ulcer/injury: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Observed handling resident's food with bare hands and acknowledged awareness of policy. | |
| Licensed Practical Nurse #1 | Stated staff must wear gloves when handling residents' food. | |
| Registered Nurse #3 | Stated policy that staff should never touch residents' food with bare hands. | |
| Infection Preventionist | Provided guidance on hand hygiene and food handling; stated staff must wear gowns and gloves for residents with wounds or indwelling devices. | |
| Licensed Practical Nurse #2 | Observed performing wound care without gown and unaware of enhanced barrier precautions due to removed signage. | |
| Assistant Director of Nursing/Educator | Removed enhanced barrier precaution signage and stated Licensed Practical Nurse #2 should have followed precautions. | |
| Food Service Director | Interviewed regarding expired and undated food items in refrigerator and food storage policies. | |
| Director of Nursing | Stated staff is to wear gowns and gloves for all direct care contact with residents who have wounds and indwelling medical devices. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 3, 2022
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with regulatory requirements for Ditmas Park Care Center.
Findings
The facility was found deficient in multiple areas including failure to develop baseline care plans within 48 hours of admission, incomplete interdisciplinary care plan meetings within 7 days, improper medication storage including unsecured medications and expired drugs, and inadequate infection prevention and control practices such as improper mask use, oxygen tubing contamination, and failure to place COVID-19 exposed residents on appropriate precautions.
Deficiencies (4)
Failure to develop a baseline care plan within 48 hours of admission for Resident #8.
Comprehensive care plan was not prepared by an interdisciplinary team including the resident for Resident #137 within 7 days of assessment.
Medications were not stored in locked compartments; an expired ampule of Digoxin was found in the emergency medication box.
Infection prevention and control deficiencies including improper mask use by staff, oxygen tubing touching the floor, and failure to place Resident #496 on contact/droplet precautions after COVID-19 exposure and positive test.
Report Facts
Residents reviewed: 38
Units reviewed: 5
Medications observed unsecured: 1
Expired medication: 1
Residents affected by infection control deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding baseline care plans and care plan meetings |
| SW #1 | Social Worker | Interviewed regarding baseline care plans and care plan meetings |
| RN #3 | Registered Nurse | Observed and interviewed regarding medication storage and emergency medication box |
| RNS | RN Supervisor | Interviewed regarding medication rounds and pharmacy returns |
| ADNS | Assistant Director of Nursing Services | Interviewed regarding emergency medication box checks |
| DNS | Director of Nursing Services | Interviewed regarding infection control and medication box procedures |
| SWC | Social Work Consultant | Interviewed regarding staffing shortages affecting care plan meetings |
| RN #3 | Registered Nurse | Observed wearing surgical mask improperly |
| CNA #1 | Certified Nursing Assistant | Observed oxygen tubing on floor and reported to nurse |
| IP | Infection Preventionist | Interviewed regarding infection control practices and COVID-19 precautions |
| LPN #1 | Licensed Practice Nurse | Interviewed regarding monitoring of Resident #496 for COVID-19 symptoms |
| ADON | Assistant Director of Nursing | Interviewed regarding COVID-19 quarantine and precautions for exposed residents |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 8, 2019
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical service requirements, specifically focusing on the handling, storage, and disposal of controlled substances.
Findings
The facility failed to ensure timely identification and removal of expired medication, as an expired controlled substance (Tramadol 50 MG) was found in the narcotics cabinet. Interviews with nursing staff and the Director of Nursing confirmed lapses in medication expiration checks and removal procedures.
Deficiencies (1)
Failure to timely identify and remove expired controlled substances from the narcotics cabinet.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding narcotics reconciliation and medication removal responsibilities |
| LPN #1 | Licensed Practical Nurse | Interviewed about medication discontinuation and narcotics expiration checks |
| RN #2 | Registered Nurse | Interviewed about narcotics counting and medication removal procedures |
| Director of Nursing | Director of Nursing | Interviewed about staff practices and pharmacy consultant visits |
| Specialty Account Representative | Pharmacy Account Representative | Interviewed about medication checks and expired medication removal |
Report
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