Articles Posted in Falls & Fractures

Cypress Garden Center for Nursing and Rehabilitation received 20 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 12, 2019. The Flushing nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not provide adequate supervision or assistive devices to prevent residents from falling. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments remain “as free of accident hazards as is possible” and to provide residents with “adequate supervision and assistance devices to prevent accidents.” An October 2016 citation found that Cypress Gardens did not ensure that a resident who had been identified as “High Risk” for falls received adequate supervision to prevent them. An inspector specifically found that in June 2016 the resident was observed on the floor after a fall, having “sustained abrasions to the forehead and left forearm.” According to the citation, the resident’s care plan interventions for falls included a chair alarm, but at the time he “did not have a bed or chair alarm in pace.” The citation found that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not implement proper measures to prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to maintain and implement “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 2019 citation found that the nursing home failed to provide such in an instance when an eye doctor consulting at the facility “did not properly clean the overbed table used or perform hand hygiene prior to completing an eye exam.” An inspector observed the eye doctor wiping off an exam table with a paper towel and then placing his equipment bag on it while there were still “stains” on the table; the doctor then moved the table into a resident’s room, according to the citation, and performed an eye exam on the resident without performing hand hygiene beforehand, although he was observed performing hand hygiene afterward.

The Riverside received 69 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 31, 2020. The Manhattan nursing home’s citations resulted from a total of six surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not implement adequate measures to prevent residents from sustaining accidents. Section 483.25 of the Federal Code provides for nursing homes to ensure residents an environment as free as possible from accident hazards, with adequate supervision to prevent accidents. A May 2019 citation found that The Riverside did not ensure adequate supervision to prevent accidents. The citation states specifically that a resident who had been identified as at risk for falls “was left unsupervised on multiple occasions,” and that another resident “was not monitored every 30 minutes after a fall as per the plan of care.” A plan of correction undertaken by the facility included the re-evaluation of the first resident, who “had no further falls,” and the in-servicing of nursing staff on the second resident’s plan of care.

2. The nursing home did not keep medication error rates adequately low. Under Section 483.45 of the Federal Code, nursing homes must maintain medication error rates that do not reach or exceed five percent. A May 2019 citation found that The Riverside’s medication error rates exceeded five percent. The citation specifically described “3 errors out of a total of 38 opportunities observed, resulting in a medication error of 7.89%.” The errors in question were connected to two residents who were administered medication outside of the allowed time. A plan of correction undertaken by the facility included re-education of the nursing staffer who administered the medication in those instances.

Henry J. Carter Skilled Nursing Facility received 8 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on February 6, 2020. The facility has also been the subject of a 2016 fine of $12,000 in connection to findings during a 2012 inspection that it violated health code provisions regarding accidents and administration. The Manhattan 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 ensure an accident-free environment. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with an environment “as free from accident hazards as is possible.” A December 2018 citation found that Henry J. Carter Skilled Nursing Facility did not ensure one resident was protected from accidents. The citation states specifically that while the resident, “who was in a persistent vegetative state” and required two persons’ assistance for bed mobility, was being turned by one Certified Nursing Assistant without assistance, her head struck the bed’s siderail. The citation states that the resident “sustained laceration, bleeding, swollenness, and bruising to her forehead.” According to the citation, the CNA in question was not disciplined by the facility or provided with education, nor removed from the resident’s unit. The citation states that this deficiency had the “potential to cause more than minimal harm.

2. The nursing home did not adequately ensure the thorough investigation of allegations of misconduct. Under Section 483.12 of the Federal Code, nursing home facilities are required to investigate, and provide evidence of the investigations thereof, any allegations of abuse, neglect, or mistreatment. A December 2018 citation found that Henry J. Carter Skilled Nursing Facility did not ensure the thorough investigation of an incident in which a resident “was observed on the floor in her room face down at the bedside with bleeding and laceration to her chin.” The citation states that while the resident was transferred to the hospital, the nursing home did not seek an “interview or written statement” from the Certified Nursing Assistant who found the resident in that state, and thus did not rule out the possibility of abuse, neglect, or mistreatment. The citation describes this deficiency as having “potential to cause more than minimal harm.”

The Valley View Center for Nursing Care and Rehabilitation received 43 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The Goshen 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 ensure an accident-free environment. Section 483.25 of the Federal Code requires nursing homes to keep resident environments “as free of accident hazards as is possible.” An August 2019 citation found that The Valley View Center for Nursing Care and Rehabilitation did not ensure such for two residents. The citation states specifically that a resident who was dependent on the assistance of two persons for bed mobility, toilet use, and transfer was transferred after restroom use by one person instead of two. The citation also states that another resident sustained a laceration to her leg while being transferred to her wheelchair from her bed with the assistance of a sliding board. A review of the incident found that the Certified Nursing Assistants who transferred the resident “were not trained prior to the date of the accident.” The citation states that these deficiencies had the “potential to cause more than minimal harm.”

2. The nursing home did not implement necessary steps to prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” An August 2019 citation found that The Valley View Center for Nursing Care and Rehabilitation did not provide such an environment. A surveyor specifically found that the nursing home did not ensure its potable water system receiving required testing for Legionella and other water-borne pathogens. The surveyor also found that facility staff did not follow “proper hand hygiene to prevent cross contamination and the spread of infection for 3 residents.” A plan of correction undertaken by the facility included the testing of the water system and the education of relevant staff on proper hand hygiene.

Highland Rehabilitation and Nursing Center received 33 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The Middletown 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 accidents. Under Section 483.25 of the Federal Code, nursing home facilities must “ensure that the resident environment remains as free of accident hazards as is possible; and [that] each resident receives adequate supervision and assistance devices to prevent accidents.” A March 2016 citation found that Highland Rehabilitation and Nursing Center did not ensure residents’ environment was sufficiently free of accident hazards, nor that two residents were provided adequate supervision. The citation states specifically that the facility did not implement measures “to minimize or prevent injuries relating to falling out of bed unto [sic] a hard surface” for one resident, and that the facility nursing staff did not ensure the other resident wore proper footwear to prevent falls. A plan of correction undertaken by the facility included the updating of the residents’ care plans with new interventions to prevent falls.

2. The nursing home did not meet food safety standards. Section 483.60 of the Federal Code states that nursing homes just “Store, prepare, distribute and serve food in accordance with professional standards for food service safety.” An April 2018 citation found that Highland Rehabilitation and Nursing Center did not ensure the food items in “nourishment refrigerators” in certain nursing unites “were stored in accordance with acceptable standards.” The citation states specifically that food in one fridge was not labeled with a resident’s name and was outdated, in contravention of facility policy; that another food item was labeled with a name but not dated; and that outdated food was also present in the fridge. A plan of correction undertaken by the facility included the discarding of the outdated and undated food.

South Shore Rehabilitation and Nursing Center received 43 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 16, 2020. The Freeport 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 keep residents free from medication errors. Section 483.45 of the Federal Code requires nursing homes to ensure residents are “free of any significant medication errors.” A February 2019 citation found that South Shore Rehabilitation and Nursing Center did not ensure such for one resident. The citation states specifically that the resident did not receive four doses of an anti-arrhythmic medication, as ordered by their physician. In an interview, the facility’s Director of Nursing stated that “the medication was not available for the resident, and the MD was not notified of the unavailability of the medication.” The citation states the deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not implement adequate accident prevention measures. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments are as free as possible of accident hazards, and that residents received “adequate supervision and assistance devices to prevent accidents.” A March 2016 citation found that South Shore Rehabilitation and Nursing Center did not ensure a resident identified as at risk for falls was provided adequate supervision assistance devices. The citation states specifically that while the resident’s care plan documented a chair alarm as one of their fall-prevention interventions, an inspector observed the resident without the chair alarm in place. In an interview, one of the facility’s charge nurses stated that she did not know why the alarm was not in place; in a separate interview, a Certified Nursing Assistant stated that the resident “was supposed to have a chair alarm but she forgot to place it on her as she was in a hurry” to get the resident to therapy.

Sunharbor Manor received 32 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 16, 2020. The facility has also been the subject of a 2010 fine of $10,000 in connection to findings that it violated health code provisions regarding quality of care. The Roslyn Heights 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 protect residents from abuse. Section 483.12 of the Federal Code ensures nursing home residents the right to freedom from abuse. A July 2019 citation found that Sunharbor Manor did not ensure this right for one resident. The citation states specifically that when a Licensed Practical Nurse approached the resident “from behind and injected him with a syringe through his long-sleeved shirt,” the resident responded with agitation and “tried to hit the nurse,” resulting in the nurse pushing the resident “to the floor causing him to fall sideways in his wheelchair and then to the floor.” In an interview, the facility’s Director of Nursing stated that an investigation she conducted ended in the conclusion that “there was possible abuse.” A plan of correction undertaken by the facility included the termination of the nurse.

2. The nursing home did not adequately protect residents from the administering of unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing home residents’ drug regimens “must be free from unnecessary drugs.” A February 2017 citation found that Sunharbor Manor did not ensure one resident’s drug regimen “had adequate indications for its use.” The citation states specifically that the resident, who “had no mood or behavior problems” but did have short- and long-term memory problems, received an antipsychotic and antidepressant medication, although the facility’s Psychiatrist stated that “age related cognitive decline was not the appropriate indication” for one of the medications. A plan of correction undertaken by the facility included the review and revision if necessary of its policy and procedure on antipsychotic medication.

The Amsterdam at Harborside received 19 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 16, 2020. The Port Washington 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 provide residents with adequate supervision. Section 483.25 of the Federal Code requires nursing homes to provide residents with “adequate supervision and assistance devices to prevent accidents.” A December 2019 citation found that The Amsterdam at Harborside did not provide such for one resident. The citation states specifically that an inspector observed a resident’s companion providing them with “nursing floor ambulation without supervision of a facility staff member,” despite facility policy stating that companions “are not permitted to physically help residents with exercises.” In an interview, the facility’s Director of Nursing Services stated that he had been providing supervision prior to the inspector’s observation, but “had to step away” to assist another staff member. The citation states that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not prevent significant medication errors. Under Section 483.25 of the Federal Code, nursing homes must take steps to ensure residents’ drug regimens are “free of any significant medication errors.” A May 2016 citation found that the Amsterdam at Harborside did not ensure such for one resident. The citation specifically states that one resident was administered the 100 mcg of a medication rather than the 50 mcg advised by their physician. In an interview, the facility’s Director of Nursing stated that an investigation determined that the wrong dosage of the medication was delivered by the pharmacy and administered to the resident “for at least three days.” The resident’s primary care physician described this as “a significant error.”

Hill Haven Nursing Home suffered 16 fatalities from Covid-19 as of July 12, 2020, state records report. The nursing home also received 29 citations over violations of public health code between 2016 and 2020, according to health records accessed on July 13, 2020.  The Webster 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 protect residents from neglect. Section 483.12 of the Federal Code stipulates that nursing homes must ensure residents are kept free from abuse and neglect. A November 2019 citation found that Hill Haven Nursing Home did not ensure such for one resident. The citation states specifically that the resident “did not receive incontinence care, positioning, or bedtime care for two consecutive shifts resulting in skin issues.” After a Certified Nursing Assistant reported to a Licensed Practical Nurse that it appeared the resident had not received care—that the resident “was still sitting in the chair, wearing the same clothes as the previous day, and was soaked with urine and feces through the incontinence brief and the pants”—the Registered Nurse Manager initiated an investigation and found that the resident had not received care over two shifts and “remained in the chair all nigh.” A plan of correction undertaken by the facility included the re-education and disciplining of relevant staff.

2. The nursing home did not adequately protect residents from accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments are kept as free as possible of accident hazards, and that residents are provided with adequate supervision to prevent accidents. A July 2019 citation found that Hill Haven Nursing Home did not ensure such. The citation specifically describes a resident who “rolled out of bed and was found with his legs resting on the baseboard heater that was next to his bed” and sustained a redacted injury to hi slower extremities. A plan of correction undertaken by the facility included the relocation of the resident to another room with a bed that was further from the baseboard heater.

The Pines at Poughkeepsie Center for Nursing & Rehabilitation suffered 19 fatalities from Covid-19 as of July 12, 2020, state records report. The nursing home also received 12 citations over violations of public health code between 2016 and 2020, according to health records accessed on July 13, 2020.  One of those citations concerns findings that the facility’s infection control procedures were deficient. The Poughkeepsie nursing home’s citations resulted from a total of two surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not take adequate steps to prevent infection. Section 483.30 of the Federal Code stipulates that nursing homes must create and maintain a program designed to prevent and control infection and disease. A December 2018 citation found that Pines at Poughkeepsie Center for Nursing & Rehabilitation did not ensure such. The citation stats specifically that staff did not follow proper hand hygiene during a lunch meal observation, and further that staff did not perform proper gloving and hand hygiene during wound care treatment. During the meal observation, a staff member was observed picking up her badge from the floor after it fell and placing it back on her clothing, then reaching over and holding the resident’s arm and continuing to assist the resident with lunch meals and fluid, without first washing her hands. In the same meal observation, a Certified Nursing Assistant was observed removing the leg rests from a resident’s wheelchair, placing them on the floor, placing her hand on the resident’s arm, then leaving the resident, removing a lunch tray from a dining cart, delivering it to another resident, opening it, cutting the meat, and opening the milk container, all without being observed washing her hands. With respect to the wound observation, a Registered Nurse Manage was observed washing her hands, preparing a dressing field, donning gloves to remove the soiled dressing that had drainage on it, and cleansing the wound without removing the soiled gloves or washing her hands. A plan of correction undertaken by the facility included the in-servicing of relevant staff.

2. The nursing home did not maintain low enough medication error rates. Section 483.45 of the Federal Code requires nursing homes to ensure that “medication error rates are not 5 percent or greater.” A December 2018 citation found that The Pines at Poughkeepsie Center for Nursing & Rehabilitation did not ensure such. The citation states specifically that in one instance, a resident was incorrectly administered eyedrops; in another, a resident was not administered insulin at the proper time. A plan of correction undertaken by the facility included the in-servicing of relevant employees.

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