Articles Posted in Choking/Aspiration

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Livingston Hills Nursing and Rehabilitation Center has been cited 66 times since 2017 for failing to properly care for patients’ pressure ulcers and for failing to take proper preventative measures to avoid any further injuries or infections.

Livingston Hills Nursing and Rehabilitation Center has received 66 citations for violations of public health code between 2017 and 2021, according to records accessed on November 12, 2021. It was recently placed on the “Special Focus Facility” list maintained by the Centers for Medicare and Medicaid Services. The Livingston nursing home facility’s citations resulted from a total of eight surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate pressure ulcer care. Section 483.25 of the Federal Code requires nursing homes to ensure residents receive a professional level of care and services to promote the healing of existing pressure ulcers and prevent the development of new pressure ulcers unless medically unavoidable. An April 2019 citation found that Livingston Hills Nursing and Rehabilitation Center failed to ensure such. The citation specifically states that the nursing home did not provide adequate interventions to prevent or promote the healing of a pressure ulcer on a resident’s coccyx. The citation describes the lack of interventions added to the resident’s care plan after the resident was documented as at risk for a pressure ulcer; a review found additionally that after an ulcer was documented, there was “no care plan for the necrotic wound and/or the wound infection.” In an interview, the facility’s Medical Director said “he was not aware that there were no wound care orders to promote healing of the pressure sore” and that the resident “received a substandard of care.” A plan of correction undertaken by the facility included the education of all nursing staff. 

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New York nursing home, The Grand Rehabilitation and Nursing at Barnwell, has been in violation of public health codes 66 times in the last four years and has been cited for medication failures, failure to prevent accidents and falls, and for neglect which has lead to incontinence and pressure ulcers.

The Grand Rehabilitation and Nursing at Barnwell received 66 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on September 17, 2021. It has also received eight fines totaling $78,000 since 2012. The Valatie nursing home’s citations resulted from a total of 17 surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not adequately protect residents from neglect. Section 483.12 of the Federal Code ensures nursing home residents the right to be free from neglect. A December 2018 citation found that The Grand Rehabilitation and Nursing at Barnwell failed to ensure such. The citation specifically describes the nursing home’s failure to timely provide one resident with interventions for skin, incontinence, and pressure ulcer care; to timely provide another resident with planned interventions with skin and bladder incontinence care; and to timely provide a third resident with planned interventions for pressure ulcer development and incontinence. According to the citation, the facility left the first resident uncared for for a period of 6 hours and 10 minutes, the second resident uncared for for a period of 11 hours and 37 minutes, and the third resident uncared for for a period of 11 hours and 51 minutes. A plan of correction undertaken by the facility included the educational counseling of nurses and nursing aides.

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A nursing home in Guilderland, New York has received 10 health and safety code citations in recent years.

Our Lady of Mercy Life Center received 10 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on July 30, 2021. The Guilderland nursing home’s citations resulted from a total of three inspections by state surveyors. The violations they describe include the following: Continue reading

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A nursing home in Montgomery, New York has received 20 health and safety code citations in the last four years.

Montgomery Nursing and Rehabilitation Center received 20 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on July 24, 2021. The Montgomery nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not undertake adequate measures to prevent residents from sustaining accidents such as choking. Section 483.25 of the Federal Code requires nursing homes to ensure residents receive adequate supervision to prevent accidents. A May 2021 citation found that Montgomery Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that the facility did not ensure a resident received their prescribed diet or monitoring while eating, and as such the resident choked while eating breakfast, requiring intervention from emergency medical services. The citation goes on to state that the resident’s physician had placed an order for a chopped solids, thin liquid diet, but on the day of the choking incident the resident was given a regular meal. During the incident, according to a nurse at the facility, “no staff were assigned to monitor the resident.” The facility’s administrator states in an interview that “there was a multi system failure” contributing the resident’s choking incident, and that there “was no system for a second check in place to ensure that residents are given meals in adherence with physician’s orders.”

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A nursing home in Cohoes, New York has received 22 health and safety code citations since 2017.

Eddy Village Green received 22 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on July 15, 2021. The facility has also received four fines totaling $22,000 since 2016. The Cohoes nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not adequately protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to provide residents with environments free of accident hazards and with adequate supervision and assistive devices to prevent avoidable accidents. A 2018 citation found a pattern of failures to prevent such by Eddy Village Green. The citation specifically describes one resident for whom adequate precautions were not taken to prevent elopement; a second resident who was not provided with “identification of the correct diet order to prevent the resident from choking“; and a third resident for whom the facility failed to “ensure the head of his bed was maintained at 45 degrees” in accordance with his physician’s orders. A plan of correction included the application of a wander tag to the first resident and the re-education of relevant staff.

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A nursing home in Palatine Bridge, New York has received citations for medication errors and infection control.

Palatine Nursing Home has received 24 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on May 20, 2021. The facility also received a fine of $12,000 in 2021 in connection to findings of rule violations. The Palatine Bridge nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following: Continue reading

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The nursing home has been cited for medication errors and accident hazards, among other health code violations.

Elderwood at Hamburg suffered 26 confirmed COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Hamburg nursing home’s citations resulted from a total of four surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not employ adequate measures to prevent and control infection. Section 483.80 of the Federal Code stipulates that nursing homes must create and maintain an infection prevention and control program “designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A September 2020 citation found that Elderwood at Hamburg failed to ensure such. The citation states specifically  that the facility failed to maintain a program “to ensure the health and safety of residents to help prevent the transmission of COVID-19.” It goes on to state that the nursing home failed to maintain social distancing on two resident care units. A surveyor observed residents “sitting side by side in wheelchairs less than 6 feet apart across from the Unit 2 Nurses Station,” with face masks hanging on the back of their wheelchairs. When a Registered Nurse walked past the residents, the citation states, she “made no attempt to socially distance the residents six feet apart.” A plan of correction undertaken by the facility included Covid-19 testing for the residents in question, who were found to be negative.

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As of January 17, 2021, the New York nursing home had 22 confirmed COVID-19 deaths.

Our Lady of Peace Nursing Care Residence suffered 22 confirmed COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 13 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Lewiston nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to provide residents with sufficient supervision and assistive devices to prevent them from sustaining accidents. A January 2020 citation found that Our Lady of Peace Nursing Care Residence failed to ensure such for one resident. The citation states specifically that the resident was on aspiration precautions and that their care plan provided for “small bites and sips, alternate solids with liquids, encourage to eat slow, supervision assistance with eating.” However, the citation states, the resident was not adequately supervised during a mealtime and “was observed to cough several times.” A plan of correction undertaken by the facility included a review of aspiration precaution procedures and the re-education of nurses involved with the resident’s feeding assistance.

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The New York nursing home has also received citations for health code violations.

An outbreak of the novel coronavirus has infected 137 residents and killed 24 at The Commons at St. Anthony, a nursing home in Auburn, New York. According to a report on syracuse.com, the outbreak began on December 21, 2020, “as a wave of post-Thanksgiving Covid-19 cases began hitting the county,” per an official overseeing the home’s operations. The outbreak has affected 47 employees. Of the residents who died, 21 died at the nursing home, while three died at the hospital. Prior to the first three deaths that were reported at the nursing home on December 29, 2020, “There had been no nursing home Covid-19 deaths in Cayuga County.” As of the report’s publication on January 9, there have been 2,650 confirmed cases in Cayuga county.

According to the report, the nursing home responded to the pandemic by requiring employees to wear “gowns, gloves and face shields at all times when working with residents,” and isolated positive cases on their own floors. Employees are tested weekly, while residents are tested “on a schedule established by the state Health Department.” An infection by state health authorities found no issues with the nursing home’s infection control policies and procedures.

Elderwood at Waverly suffered 19 fatalities from Covid-19 as of July 18, 2020, per state records. The nursing home also received 17 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 20, 2020. It was additionally the recipient of a 2019 fine in connection to findings in a 2018 survey that it violated unspecified health code provisions. The Waverly nursing home’s citations resulted from a total of six surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not properly supervise residents to prevent accidents. Section 483.25 of the Federal Code requires nursing homes to ensure resident environments are kept as free as possible of accident hazards, and that residents received “adequate supervision and assistance devices to prevent accidents.” A January 2019 citation found that Elderwood at Waverly failed to ensure residents received an adequate level of supervision with the use of assistance devices. The citation specifically describes a resident with “moderate cognitive impairment” who required the assistance for transfers and walking. “The resident utilized a wheelchair and walker, was not steady when moving fro a seated to standing position and for surface to surface transfers,” according to the citation, which goes on to describe an instance in which the resident was observed “self-propelling from the dining room to her room using doorways and handrails to assist” and with her feet under her wheelchair’s leg rest foot plates; it also describes another instance in which she stood from her wheelchair to move to the other side of a table in the dining room, and another in which she self-propelled with her feet under her wheelchair’s leg rests. In an interview, the facility’s Director of Therapy stated that “any resident who self-propelled in a wheelchair with their legs and feet should not have leg rests on the chair due to the risk to fall and impeding mobility.” A plan of correction undertaken by the facility included a revision of the resident’s care plan concerning the use of leg rests.

2. The nursing home did not protect residents from abuse. Section 483.12 of the Federal Code requires nursing homes to protect each resident’s right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” An October 2018 citation found that Elderwood at Waverly failed to ensure such. The citation specifically describes a resident who “was observed on video being hit by facility staff.” According to the citation, a Registered Nurse “bent to kiss the resident on her forehead” after administering medication, at which point the resident struck theRN in the face, and the RN “responded by grabbing and slapping the resident’s left arm.” A plan of correction undertaken by the facility included the termination of the RN.

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