Inspection Reports for
The Phoenix Rehabilitation And Nursing Center
140 St Edwards St, Brooklyn, NY 11201, NY, 11201
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 23, 2024
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with professional standards of care, specifically focusing on respiratory and tracheostomy care for residents.
Findings
The facility failed to ensure that a resident requiring tracheostomy care received appropriate care consistent with professional standards. A family member was observed performing tracheostomy care without training or staff supervision, contrary to facility policy and physician orders.
Deficiencies (1)
F 0695: The facility did not provide safe and appropriate respiratory care for a resident needing tracheostomy care. A family member performed tracheostomy care without training or licensed staff supervision, using improper aseptic technique.
Report Facts
Residents sampled: 38
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Stated family member performs tracheostomy care daily | |
| Licensed Practical Nurse #1 | Reported family member performs tracheostomy care daily without known training | |
| Registered Nurse #1 | Responsible for unit nursing care, unaware family member performed tracheostomy care | |
| Director of Nursing | Stated unit nurse responsible for tracheostomy care and family must be educated if performing care |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 23, 2024
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in providing appropriate respiratory care, food storage safety, and infection prevention and control practices. Specific issues included unsupervised tracheostomy care by a family member, expired enteral feeding products, and inadequate hand hygiene by staff.
Deficiencies (3)
F 0695: The facility failed to ensure safe and appropriate respiratory care for a resident requiring tracheostomy care. A family member performed tracheostomy care without training or staff supervision, violating facility policy.
F 0812: The facility did not store food in accordance with professional standards. Multiple expired enteral feeding bottles were found in the kitchen dry storage room during inspection.
F 0880: The facility failed to maintain infection prevention and control practices. Staff did not perform hand hygiene between residents during meal assistance, and the Water Management Plan lacked acceptable pathogen level ranges for Legionella.
Report Facts
Residents sampled for tracheostomy care: 38
Expired enteral feeding bottles: 24
Expired enteral feeding boxes: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Stated family member performs tracheostomy care daily |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported family member performs tracheostomy care daily without known training |
| Registered Nurse #1 | Registered Nurse | Responsible for unit nursing care; unaware family member performed tracheostomy care |
| Director of Nursing | Director of Nursing | Responsible for nursing care; unaware family member performed tracheostomy care; stated family must be educated if performing care |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Observed not performing hand hygiene between residents during meal assistance |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Confirmed staff received in-service on hand hygiene and availability of sanitizers |
| Infection Preventionist | Infection Preventionist | Stated staff must assist residents with hand hygiene and perform hand hygiene themselves |
| Assistant Administrator | Assistant Administrator | Committed to updating Water Management Plan to include acceptable pathogen levels |
Inspection Report
Recertification
Deficiencies: 1
Date: Aug 19, 2022
Visit Reason
The inspection was conducted as part of a Recertification and Complaint survey from 08/15/2022 to 08/19/2022 to assess compliance with food storage and safety standards.
Complaint Details
The survey included a complaint investigation component as indicated by the Recertification and Complaint survey type (NY00270919).
Findings
The facility failed to ensure safe food storage practices, as expired nutritional supplements and enteral feeds were found in the kitchen's Dry Storage Room and basement Overflow Storage Room. Interviews revealed inconsistent checking and removal of expired items by staff.
Deficiencies (1)
F 0812: The facility did not ensure safe food storage was practiced, with multiple expired nutritional supplements and enteral feeds found in storage areas. Staff interviews confirmed lapses in checking and removing expired items.
Report Facts
Expired nutritional supplement bottles: 3
Expired supplement cartons and bottles: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #2 | Interviewed regarding food storage practices and checking of expiration dates | |
| Dietary Supervisor | Interviewed about frequency of storeroom checks for expired foods | |
| Food Service Director | Interviewed about rounds to check for spoiled and expired foods | |
| Administrator | Interviewed about food service clerk's log and checks for expired food items |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Oct 30, 2019
Visit Reason
The survey was conducted as a recertification (annual) survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including failure to reasonably accommodate resident needs, incomplete comprehensive care plans, improper food temperature controls, and inadequate infection prevention and control practices. Several residents were affected by these deficiencies, with issues ranging from call light accessibility to improper use of personal protective equipment (PPE) and outdated infection control policies.
Deficiencies (4)
F 0558: The facility did not ensure residents received services accommodating their needs and preferences. Resident #523's call light was repeatedly found out of reach, limiting her ability to summon assistance.
F 0656: The facility failed to develop a comprehensive person-centered care plan for Resident #213 on Contact Isolation for MRSA, lacking measurable objectives and timeframes.
F 0812: The facility did not maintain internal temperatures of cold foods at safe levels, with sandwiches observed at temperatures above 41°F during service.
F 0880: The infection prevention and control program was not maintained or reviewed annually. Staff failed to consistently wear appropriate PPE for residents on contact precautions for MRSA and Candida Auris, risking infection spread.
Report Facts
Residents sampled: 38
Residents affected by call light deficiency: 1
Residents affected by care plan deficiency: 1
Residents affected by infection control deficiency: 2
Food temperatures observed: 49
Food temperatures observed: 46
Food temperatures observed: 53
Food temperatures observed: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency for failure to wear appropriate PPE and improper infection control practices |
| RN #3 | Registered Nurse | Supervises nursing staff and provided information on call light and infection control practices |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding call light placement and resident care |
| RN #2 | Registered Nurse | Charge nurse responsible for staff education and infection control compliance |
| RN #8 | Infection Control Preventionist | Provided information on infection control practices and staff education |
| RN #5 | Registered Nurse Supervisor | Oversaw infection control policies and staff compliance |
| CNA #1 | Certified Nursing Assistant | Observed not wearing PPE when entering resident room on contact precautions |
| DNS | Director of Nursing Services | Interviewed regarding infection control policies and staff compliance |
Viewing
Loading inspection reports...
