Articles Posted in Falls & Fractures

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According to New York State Department of Health records recently accessed, Yonkers Gardens Center for Nursing and Rehabilitation received a total of 38 citations for being in violation of public health code between 2018 and 2022.

Yonkers Gardens Center for Nursing and Rehabilitation received 38 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on May 13, 2022. The Yonkers nursing home’s citations resulted from a total of 15 inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not implement adequate accident prevention measures. Section 483.25 of the Federal Code maintains that nursing homes must ensure resident environments remain as free as possible of accident hazards, while providing residents with “adequate supervision and assistance devices to prevent accidents.” A December 2021 citation found that Yonkers Gardens Center for Nursing and Rehabilitation failed to ensure such. The citation specifically describes an instance in which a resident at high risk for elopement “exited the facility through the main lobby, undetected by staff,” who did not discover them until the following day. The citation goes on to describe a separate instance in which a second resident at high risk for elopement “exited the facility twice unnoticed by the staff.” In a third instance described by the citation, a third resident at high risk from elopement exited the facility “through a tunnel that led to the hospital grounds” and was found in a park one block away from the nursing home. A plan of correction undertaken by the facility included the education and counseling of relevant staff, as well as the termination of a security guard assigned to monitor the facility’s main lobby.

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Westhampton Care Center received 17 citations for being in violation of public health code between 2018 and 2022 after a total of 4 inspections by state surveyors.

Westhampton Care Center received 17 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on May 13, 2022. The Westhampton nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not properly ensure the prevention and control of infection. Under Section 483.80 of the Federal Code, nursing homes “must establish 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 January 2022 citation found that Westhampton Care Center failed to ensure such. The citation specifically describes an instance in which a Licensed Practical Worse “did not wear appropriate personal protective equipment (PPE) when providing medications and checking blood sugar” for a resident on contact and droplet precautions. It goes on to state that the LPN “did not wear gloves while administering insulin” to the resident, and describes two separate instances in which staffers failed to wear proper PPE while tending to residents on contact and droplet precautions, in contravention of the facility’s Covid-19 policies. A plan of correction undertaken by the facility included the counseling of relevant staff.

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Sapphire Nursing at Meadow Hill has received 27 citations for being in violation of public health code between 2018 and 2022 after a total of 3 surveys were performed by state inspectors.

Sapphire Nursing at Meadow Hill received 27 citations for violations of public health code between between 2018 and 2022, according to New York State Department of Health records accessed on April 15, 2022. The Newburgh 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 prevent abuse. Section 483.12 of the Federal Code ensures nursing home residents “the right to be free from abuse.” An October 2020 citation found that Sapphire Nursing and Rehab at Meadow Hill failed to ensure such. The citation specifically describes two residents, both with “severely impaired cognition,” who were not protected from abuse. One resident, according to the citation, was involved in an incident in which a certified nursing assistant pulled their wig off and hit her head with it, “then posting the video to social media.” In a second incident described by the citation, another resident was involved in an incident in which another CNA took a picture of them “and posted it on social media without the resident’s or representative’s consent.” A plan of correction undertaken by the facility included the termination of both CNAs.

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Apex Rehabilitation & Care Center received 15 citations for being in violation of public health code between 2018 and 2022 after a total of 3 surveys by state inspectors.

Apex Rehabilitation & Care Center received 15 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 29, 2022. The Uniondale nursing home’s citations resulted from a total of 3 inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not effectively protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments are as free as possible of accident hazards. A February 2022 citation found that Apex Rehabilitation & Care Center failed to ensure such. The citation specifically describes an instance in which the facility did not move an ambulatory resident out of their room while “while there were repairs being made for an active leak,” additionally failing to put signage in place to inform the resident, who was at risk for falls, that the floor was wet. In an interview, a certified nursing aide acknowledged that the resident “could slip on the floor.” A housekeeper said in another interview that “they should have put a sign that indicated the floor was wet,” due to the risk that the resident could fall. A plan of correction undertaken by the facility included the educational counseling of staff assigned to the resident.

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Hempstead Park Nursing Home has received 43 citations for being in violation of public health code between 2018 and 2022 after a total of 13 surveys by state inspectors.

Hempstead Park Nursing Home received 43 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 22, 2022. The Hempstead nursing home’s citations resulted from a total of 13 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from abuse. Section 483.12 of the Federal Code provides nursing home residents with “the right to be free from abuse.” A November 2021 citation found that Hempstead Park Nursing Home failed to ensure such for two residents. The citation specifically describes one resident with dementia who kicked another resident, who then allegedly threw a garbage can at the first resident. The first resident sustained “two small lacerations” on their legs, according to the citation, which describes facility policy stating that “physical abuse is inappropriate.” A plan of correction undertaken by the facility included the review and revision of both residents’ care plans and the in-servicing of facility staff on abuse. 

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Isabella Geriatric Center has received 21 citations for being in violation of public health code between 2018 and 2022 after a total of 5 surveys by state inspectors had lead to the discovery of multiple deficiencies within the Manhattan nursing home.

Isabella Geriatric Center has received 21 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 1, 2022. The Manhattan nursing home’s citations resulted from a total of 5 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 stipulates that nursing homes must provide residents with adequate supervision to prevent accidents. A July 2021 citation found that Isabela Geriatric Center failed to ensure such. The citation specifically describes an instance in which a resident being escorted to an outside appointment was not secured in their chair with a safety belt. As a result, the citation states, the resident slid from their chair to the floor of an ambulette, sustaining “bilateral fractures of the lower extremities.” A plan of correction undertaken by the facility included the re-education of relevant staff.

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Northern Manor Geriatric Center has received 23 citations for being in violation of public health code since 2018 after a total of 5 surveys were performed by state inspectors.

Northern Manor Geriatric Center has received 23 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 1, 2022. The Nanuet nursing home’s citations resulted from a total of five surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not take adequate steps to prevent elopement. Under Section 483.25 of the Federal Code, nursing homes must provide residents with adequate supervision and assistance devices to prevent accidents, including elopement. A July 2021 citation found that Northern Manor Geriatric Center failed to ensure such. The citation specifically describes a resident identified as an elopement risk, whose care plans included 30-minute checks. According to the citation, these checks were not provided on one date between 6am and 7am, during which the resident “climbed out a window on the third floor and fell on to cement.” Facility staff discovered the resident at 7am, and the resident was subsequently taken to the hospital and put on mechanical ventilation with fractures to their pelvis and ankle. The citation describes this deficiency as posing “Immediate jeopardy to resident health or safety.”

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The New Jewish Home has received 39 citations for being in violation of public health code since 2018 after a total of 10 surveys were performed by state inspectors and lead to the discovery of multiple deficiencies.

The New Jewish Home has received 39 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on March 25, 2022. The Manhattan nursing home’s citations resulted from a total of 10 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately 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 December 2021 citation found that The New Jewish Home failed to ensure such. The citation specifically describes in which a resident was given an incorrect dosage of a redacted medication. In an interview, the registered nurse who administered the medication said, “To tell you the truth, I was not looking at the percentage and I did not read the instructions that after opening it has to be refrigerated and to use only within 96 hours.” A plan of correction undertaken by the facility included the re-education of the nurse in question. 

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Haym Solomon Home for the Aged has received 22 citations for being in violation of public health code since 2018 after state inspectors found deficiencies within the Brooklyn facility.

Haym Solomon Home for the Aged has received 22 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on March 25, 2022. The Brooklyn 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 take adequate measures to prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents receive adequate supervision to prevent accidents. A June 2018 citation found that Haym Solomon Home for the Aged failed to ensure such for one resident. The citation specifically describes an instance in which a Certified Nursing Assistant “did not follow the plan of care and provide necessary supervision to a resident during a shower.” The resident in question required two-person assistance for showers, and was left alone by the CNA. After being left alone, the citation states, the resident fell from their shower chair. The CNA in question “did not call for the assistance of a nurse” after the resident fell, instead lifting the resident on their own and returning them to the chair. The citation states that the resident suffered a redacted injury. A plan of correction undertaken by the facility included the counseling and disciplining of the CNA.

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Cobble Hill Health Center has received 22 citations for being in violation of public health code since 2018 after a total of 5 surveys by state inspectors found multiple deficiencies within the Brooklyn nursing home.

Cobble Hill Health Center has received 22 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on March 19, 2022. The Brooklyn nursing home’s citations resulted from a total of five surveys by state inspectors. The deficiencies 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 provide residents with adequate supervision to prevent accidents. A December 2021 citation found that Cobble Hill Health Center failed to ensure such. The citation specifically describes who was “allowed Out on Pass (OOP) unescorted without a safety assessment or physician’s orders.” The resident did not return to the nursing home at the end of the day, the citation states, noting that the facility “was unable to locate” them. The facility received a call from a hospital reporting that the resident had fallen at home and was admitted, said the citation, adding that “there was no documented evidence” in the resident’s medical record that they had been assessed to determine the risk of leaving the facility unescorted. A plan of correction undertaken by the facility included the education of nursing staff on out-on-pass orders.

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