Inspection Reports for The Chateau At Brooklyn Rehab And Nursing Center
NY, 11229
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
141% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Renewal
Deficiencies: 3
Date: Jun 21, 2024
Visit Reason
The inspection was conducted as a Recertification survey from 06/13/2024 to 06/21/2024 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in honoring residents' rights to manage their financial affairs, specifically failing to provide quarterly statements to Resident #9. Additionally, the facility did not develop and implement comprehensive care plans for residents' pain management and respiratory care needs, notably for Residents #6 and #22.
Deficiencies (3)
Facility did not ensure Resident #9 received quarterly statements advising of the balance in their personal fund account.
No comprehensive care plan was developed to address Resident #6's chronic pain despite medical orders and documented pain assessments.
No care plan was created for Resident #22 receiving oxygen therapy as ordered by the physician.
Report Facts
Resident personal fund balance: 5357.28
Residents reviewed for pain management: 6
Residents reviewed for respiratory care: 2
Total sampled residents: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding responsibility for putting in residents' care plans |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Interviewed regarding care plan reviews and confirmation of missing pain care plan for Resident #6 |
| Registered Nurse Manager and Clinical Educator #1 | Registered Nurse Manager and Clinical Educator | Interviewed about care plan creation process and confirmation of missed pain care plan for Resident #6 |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding oversight of care plan entry and review, confirmed pain care plan should have been in place for Resident #6 |
| Medicaid/Finance Coordinator | Interviewed by telephone regarding Resident #9's personal fund account and statement distribution | |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan responsibilities and lack of care plan for Resident #22's oxygen therapy |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 21, 2024
Visit Reason
The inspection was conducted as a Recertification and Complaint survey from 06/13/2024 to 06/21/2024, triggered by allegations of misappropriation of property and narcotic diversion by a Licensed Practical Nurse.
Complaint Details
The complaint investigation revealed Licensed Practical Nurse #3 diverted narcotic medications for two residents (Resident #232 and Resident #334). The nurse was observed on video removing medications from the locked medication cart and admitted to taking the medication for personal use. The nurse was terminated and arrested. The case was reported to the New York City Police Department, Department of Health, Bureau of Narcotics Enforcement, and the Office of the Professions.
Findings
The facility failed to protect residents from misappropriation of property when Licensed Practical Nurse #3 diverted narcotic medications intended for two residents. The nurse admitted to taking medication for personal use and was terminated and arrested. The facility also failed to timely report all suspected abuse and diversion to the Department of Health and did not ensure pharmaceutical services met professional standards, including accurate narcotic receipt and documentation.
Deficiencies (5)
Failure to protect residents from wrongful use of belongings or money, specifically narcotic diversion by Licensed Practical Nurse #3.
Failure to timely report suspected abuse and diversion of narcotics to the Department of Health for Resident #334.
Failure to ensure pharmaceutical services met professional standards, including accurate receipt and documentation of narcotics.
Failure to provide pharmaceutical services that assure accurate receipt, record keeping, and reconciliation of controlled substances.
Failure to provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Report Facts
Narcotic tablets diverted: 56
Narcotic tablets diverted: 30
Narcotic tablets received: 60
Narcotic tablets received: 60
Narcotic tablets documented received: 30
Narcotic tablets documented received: 30
Residents reviewed: 38
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in narcotic diversion and misappropriation findings; admitted to taking medication for personal use; terminated and arrested. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Reported missing narcotics during narcotic count on 3/28/2024. |
| Registered Nursing Supervisor #1 | Registered Nursing Supervisor | Delivered narcotics to Licensed Practical Nurse #3 on 3/27/2024; did not monitor narcotic quantities documented. |
| Director of Nursing Services | Director of Nursing | Conducted investigation, reported findings, and interviewed staff regarding narcotic diversion. |
| Administrator | Facility Administrator | Interviewed regarding video surveillance and reporting of narcotic diversion. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 12
Date: Jun 21, 2024
Visit Reason
Complaint survey with 6 health and 6 life safety citations, all Level 2 severity, corrected by August 2024.
Findings
Complaint survey with 6 health and 6 life safety citations, all Level 2 severity, corrected by August 2024.
Deficiencies (12)
Develop/implement comprehensive care plan — quality of care
Free from misappropriation/exploitation — quality of care
Pharmacy srvcs/procedures/pharmacist/records — quality of care
Protection/management of personal funds — quality of care
Reporting of alleged violations — quality of care
Services provided meet professional standards — quality of care
Develop ep plan, review and update annually — life safety
Electrical systems - other — life safety
Electrical systems - receptacles — life safety
Gas equipment - labeling equipment and cylind — life safety
Hazardous areas - enclosure — life safety
Portable fire extinguishers — life safety
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 25, 2022
Visit Reason
The inspection was conducted as part of the Recertification survey to assess compliance with regulatory requirements and ensure the facility meets standards for resident care and safety.
Findings
The facility was found deficient in developing and implementing comprehensive, person-centered care plans with measurable objectives and timeframes, specifically for a resident with diabetes mellitus. Additionally, unsafe food handling and storage practices were observed, including several expired food items in the kitchen refrigerators.
Deficiencies (2)
Failure to develop and implement a comprehensive care plan that meets all the resident's needs, including measurable objectives and timeframes, specifically for a resident with diabetes mellitus.
Failure to ensure safe food handling and storage practices to prevent food-borne illness, evidenced by several expired food items observed in kitchen refrigerators.
Report Facts
Residents reviewed for Unnecessary Medications: 35
Residents reviewed for Unnecessary Medications with deficiency: 1
Blood Sugar Monitoring frequency: 3
Expired food items observed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Manager #2 | Interviewed regarding care plan initiation and responsibility | |
| Director of Nursing (DON) | Interviewed regarding nursing responsibilities for care plan initiation and review | |
| Dietary Aide (DA) | Interviewed regarding food preparation and expiration date checks | |
| Assistant Food Service Director (AFSD) | Interviewed regarding food expiration date checks | |
| Food Service Director (FSD) | Interviewed regarding food safety rounds and responsibilities |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: May 25, 2022
Visit Reason
Complaint survey with 5 health and 4 life safety citations, all Level 2 severity, corrected by June 2022.
Findings
Complaint survey with 5 health and 4 life safety citations, all Level 2 severity, corrected by June 2022.
Deficiencies (9)
Develop/implement comprehensive care plan — quality of care
Food procurement, store/prepare/serve-sanitary — quality of care
Free of accident hazards/supervision/devices — quality of care
Notify of changes (injury/decline/room, etc.) — quality of care
Quality of care — quality of care
Emergency lighting — life safety
Means of egress - general — life safety
Sprinkler system - maintenance and testing — life safety
Vertical openings - enclosure — life safety
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 14, 2022
Visit Reason
Complaint survey with 1 health citation related to reporting of alleged violations, Level 2 severity, corrected by June 2022.
Findings
Complaint survey with 1 health citation related to reporting of alleged violations, Level 2 severity, corrected by June 2022.
Deficiencies (1)
Reporting of alleged violations — quality of care
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 24, 2019
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found deficient in maintaining residents' dignity related to catheter care, ensuring privacy and confidentiality, maintaining a safe and clean environment, developing complete care plans, and implementing infection prevention and control protocols. Specific issues included visible urine-filled catheter tubing in common areas, lack of leg bag use for catheterized residents, soiled and damaged furniture and environment, incomplete care plans for catheter use, and inadequate infection control signage for a resident on contact precautions.
Deficiencies (5)
Residents with catheters were observed in common areas with visible urine-filled catheter tubing, indicating failure to maintain dignity.
Residents' privacy and confidentiality were not maintained due to visible urine-filled catheter tubing in common areas.
Housekeeping and maintenance services were inadequate, with soiled, faded, torn chairs, holes in walls, peeling plaster, missing blinds, and dirty equipment.
Care plan for a resident with a urinary catheter lacked measurable goals, objectives, and interventions.
Infection control practices were not maintained; signage for contact precautions was missing or not visible on a resident's room door.
Report Facts
Residents reviewed for Catheter Care: 2
Resident units with environmental deficiencies: 2
BIMS score: 9
BIMS score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed about catheter care and leg bag use for Resident #162 |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about catheter care and leg bag use for Resident #165 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about catheter care and privacy bags |
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed about care plan development and catheter care protocols |
| Director of Nursing | Director of Nursing | Interviewed about facility compliance and catheter care protocols |
| Director of Facility Services | Director of Facility Services | Interviewed about housekeeping and maintenance services |
| Administrator | Administrator | Interviewed about remodeling and housekeeping staffing |
| Visitor | Interviewed regarding infection control signage and contact precautions | |
| Resident #65 | Resident on contact precautions with infection control signage issues |
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