Articles Posted in Falls & Fractures

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East Haven Nursing and Rehabilitation Center has received a total of 16 citations from three separate state inspections since 2017.

East Haven Nursing & Rehabilitation Center received 16 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 14, 2022. The Bronx nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not take adequate steps to prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with “adequate supervision and assistance devices to prevent accidents.” A February 2020 citation found that East Haven Nursing & Rehabilitation Center failed to ensure such. The citation specifically states that after a resident receiving one-on-one supervision suffered a fall in her room, there was no investigation initiated. The citation goes on to state that the resident had suffered “3 or more falls” in the previous three months, and had been assessed as at high risk for falls. In an interview, the facility’s Assistant Director of Nursing said that an accident report indicated that “resident was found on the floor and not that the 1:1 aide assigned to the resident actually witnessed the fall,” despite the aide’s duty to “constantly” supervise and observe the resident. The ADNS added that he believed an investigation was conducted “but cannot provide any information as to how the resident was found on the floor when a 1:1 aide was scheduled to be watching her.” A plan of correction undertaken by the facility included the education of the ADNS by the Director of Nursing. 

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Bishop Rehabilitation and Nursing Center has received over 90 citations since 2017 and has recently been placed on a list for failing to properly care for its residents.

Bishop Rehabilitation and Nursing Center has received 91 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 Syracuse nursing home facility’s citations resulted from a total of 17 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not employ adequate measures to prevent falls. Under Section 483.25 of the Federal Code, nursing homes must provide residents with adequate supervision and assistance devices to prevent accidents. A September 2021 citation found that Bishop Rehabilitation and Nursing Center failed to ensure such. The citation specifically describes a resident who “did not have a supervision plan in place to ensure safety during meals while receiving a mechanically altered diet.” The resident consequently “sustained several falls.” According to the citation, the nursing home did not thoroughly investigate the falls for the purpose of preventing further falls. The citation goes on to describe multiple instances during which the resident was eating in their room with no staff president, despite care instructions requiring supervision while eating. The citation describes these deficiencies as having the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the re-education of staff.

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Van Duyn Center for Rehabilitation and Nursing in Syracuse has received a total of 89 citations for being in violation of public health and safety codes and has been previously placed on a list that could make this nursing home one of the worst facilities.

Van Duyn Center for Rehabilitation and Nursing has received 89 citations for violations of public health and safety code between 2017 and 2021, according to New York State Department of Health records accessed on October 15, 2021. The Syracuse nursing home’s citations resulted from a total of 20 surveys by state inspectors. The most recent inspection—on June 18th, 2021—described the following deficiencies:

1. The nursing home did not adequately prevent accidents. Under Section 483.25 of the Federal Code, nursing homes must ensure residents receive an environment as free as possible of accident hazards. A June 2021 citation found that Van Duyn Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically that the facility lacked a plan to evacuate a resident who weighed around 700 pounds and “was not mobile” from their room during an emergency. As the citation describes, the resident “required assistance with activities of daily living” and their care plan documented the need of a mechanical lift. In an interview, staff members said the resident’s bed would not fit through their room’s doorway and that they were “not trained in bariatric evacuation.” Both a certified nursing aide and a licensed practical nurse stated that they had not been trained in bariatric evacuation and were not sure how to evacuate the resident. In an interview, the facility’s Director of Nursing said they were not certain whether there was an evacuation plan for bariatric residents. A plan of correction undertaken by the facility included the development of an evacuation plan for the resident, the training of staff, and the purchase of necessary equipment.

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Van Duyn Center for Rehabilitation and Nursing in Syracuse has received a total of 89 citations and was placed on a list by the federal government after inspectors found serious issues that could name this nursing home one of the worst facilities in the country.

A “troubled” nursing home in Syracuse, New York has been placed on the federal government’s “special focus facilities list,” meaning it may end up named one of the worst-performing facilities in the country for a second time, according to a report by Syracuse.com. Continue reading

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The Ellicott Center for Rehabilitation and Nursing has received over 70 citations in the last four years for failing to arrange proper accident prevention among patients, lacking sufficient care for pressure ulcers, and for failing to avert any medication errors.

Ellicott Center for Rehabilitation and Nursing has received 72 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on October 1, 2021. The facility has also received five fines totaling $40,000 since 2011. The Buffalo nursing home’s citations resulted from a total of 13 inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate accident-prevention measures. Section 483.25 of the Federal Code requires nursing homes to ensure residents an accident-free environment. A February 2020 citation found that Ellicott Center for Rehabilitation and Nursing failed to ensure such. The citation specifically describes an instance in which the facility failed to ensure a shower chair lift fit through a shower room doorway. As a result, a resident “sustained a leg laceration, was transferred to the hospital and required 18 sutures.” In a separate incident, a resident was transferred without the use of a mechanical lift or safety devices as planned, and consequently suffered “actual harm” A plan of correction undertaken by the facility included the counseling of nursing staff.

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St. Margaret’s Center has been in violation of public health codes and has received 31 citations in the last four years for failing to prevent accidents and injuries and for lacking proper infection control and not following the proper safety precautions when caring for patients’ cuts and wounds.

St. Margaret’s Center received 31 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on September 25, 2021. It has also received three fines totaling $36,000 since 2015. The Albany nursing home’s citations resulted from a total of seven surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not adequately prevent accidents. Nursing home residents have the right to an environment as free as possible of accident hazards under Section 483.25 of the Federal Code. A February 11 citation found that St. Margaret’s Center failed to ensure such. The citation specifically describes the facility’s failure to ensure the siderails on a resident’s crib “were properly positioned and latched to prevent a fall from the crib.” According to the citation, a Certified Nursing Aide observed the resident flip out of their crib, after which the resident was observed sitting up on the floor, “crying and bleeding from the right side of the mouth.” A plan of correction undertaken by the facility included the re-education of nursing staff on the proper use of crib rails.

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A nursing home in Glen Cove, New York has received more than a dozen health and safety code citations in the last four years.

Emerge Nursing and Rehabilitation at Glen Cove received 14 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on August 14, 2021. The Glen Cove nursing home’s citations resulted from a total of five surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not adequately prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents an environment as free as possible of accident hazards and with adequate supervision to prevent accidents. A February 2021 citation found that Emerge Nursing and Rehabilitation at Glen Cove failed to ensure such. The citation states specifically that the nursing home left “numerous chemical agents… unattended or unsecured” in two resident units. The cleaning chemicals in question included Fresh Scent Deodorizer Concentrate, Non-Acid Disinfectant Bathroom Cleaner, Glass Cleaner and Protector Concentrate, HB Quad Disinfectant Cleaner Concentrate, Peroxide Cleaner Concentrate, Lysol Foaming, and Lemon Polish. In an interview, the facility’s Director of Housekeeping said the items “should not have been left unsecured” and “were potentially hazardous to residents if ingested.” A plan of correction undertaken by the facility included the in-servicing of a housekeeper.

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A nursing home in Gowanda, New York has received citations for violations of health and safety code.

Gowanda Rehabilitation & Nursing Center received 28 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on August 14, 2021. The Long Beach 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 provide adequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with professional levels of care to promote the healing and prevent the infection of pressure ulcers. A May 2019 citation found that Gowanda Rehabilitation & Nursing Center failed to ensure such for two residents. The citation states specifically that there was no “weekly assessment by a qualified person after a pressure area was identified” for one resident, and that for the other there was “a five-day delay in assessment  by a qualified person” following the identification of a pressure area. A plan of correction undertaken by the facility included a full-house audit, the revision of the facility’s skin care protocol, and the educational counseling of nursing staff who did not properly document a resident’s pressure area.

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A nursing home in Long Beach, New York has received numerous citations in the last four years.

Park Avenue Extended Care Facility received 14 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on August 14, 2021. The Long Beach nursing home’s citations resulted from a total of four surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not properly prevent medication errors. Under Section 483.45 of the Federal Code, nursing home residents have the right to be “free of any significant medication errors.” A February 2020 citation found that Park Avenue Extended Care Facility failed to ensure such. The citation states specifically that the nursing home did not ensure one resident’s medication was administered in the parameters ordered by the physician. In an interview, a Licensed Practical Nurse said she had followed the instructions on the medication’s blister pack, and was not aware they reflected old physician’s orders that did not reflect current orders. In an interview, the facility’s Director of Nursing Services said that “the old blister pack should have been returned to the pharmacy by any one of the nurses on duty and replaced with the newly ordered medication blister pack.” A plan of correction undertaken by the facility included the educational counseling of the nurse in question.

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A nursing home in Albany, New York has received 27 health and safety code citations since 2017.

Daughters of Sarah Nursing Center received 27 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on July 16, 2021. The facility has also received three fines totaling $22,000 since 2014. The Albany nursing home’s citations resulted from a total of six inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not adequately protect residents from abuse. Under Section 483.12 of the Federal Code, nursing home residents have “the right to be free from abuse.” An August 2020 citation found that Daughters of Sarah Nursing Center failed to ensure such for one resident. The citation specifically describes a resident with severe cognitive impairment who was abused by a resident with mildly impaired cognition. According to the citation the abuse in question involved “non-consensual sexual intrusion, touching intimate body parts or the clothing covering intimate body parts.” A plan of correction undertaken by the facility included the movement of the victim to a new unit and the placement of the other resident on one-to-one observation and his movement to a different area to avoid contact with the victim.

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