Inspection Reports for
The Chateau At Brooklyn Rehab And Nursing Center
NY, 11229
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Inspection Report — Jun 21, 2024
Renewal CMS
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.
Citations (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 — Jun 21, 2024
Complaint Investigation State
Date: Jun 21, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2026 with citation and complaint history.
Complaint Details
The state logged 106 complaints about this facility; 5 led to on-site inspections. Four citations resulted from those complaints.
Findings
Across 4 inspections, 3 had no citations while 1 inspection resulted in 12 citations split evenly between standard health and life safety code violations. The facility received 106 complaints with 5 on-site inspections and no formal enforcement actions.
Citations (12)
Standard Health Citation — quality of care: Develop and implement a comprehensive care plan was deficient.
Standard Health Citation — quality of care: Failed to ensure residents were free from misappropriation or exploitation.
Standard Health Citation — quality of care: Pharmacy services, procedures, pharmacist, and records were inadequate.
Standard Health Citation — quality of care: Protection and management of personal funds was deficient.
Standard Health Citation — quality of care: Reporting of alleged violations was inadequate.
Standard Health Citation — quality of care: Services provided did not meet professional standards.
Life Safety Code Citation — NFPA requirements: Failed to develop, review, and update emergency plan annually.
Life Safety Code Citation — NFPA requirements: Electrical systems other than receptacles were deficient.
Life Safety Code Citation — NFPA requirements: Electrical receptacles were not compliant.
Life Safety Code Citation — NFPA requirements: Gas equipment labeling for equipment and cylinders was inadequate.
Life Safety Code Citation — NFPA requirements: Hazardous areas enclosure was deficient.
Life Safety Code Citation — NFPA requirements: Portable fire extinguishers were not compliant.
Report Facts
Inspections on page: 4
Total violations/deficiencies cited: 12
Inspections with violations: 1
Inspections without violations: 3
Total complaints: 106
On-site inspections from complaints: 5
Citations issued from complaints: 4
Number of enforcement actions: 0
Inspection Report — May 25, 2022
Annual Inspection CMS
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.
Citations (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 — Jun 24, 2019
Annual Inspection CMS
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.
Citations (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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