Articles Posted in Falls & Fractures

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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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The New York nursing home has received numerous health code citations.

Chasehealth Rehab and Residential Care 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 9, 2021. The New Berlin 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 take adequate steps to prevent accidents. Under Section 483.25 of the Federal Code, nursing homes must ensure residents receive adequate supervision and assistance devices to prevent accidents. A May 2021 citation found that Chasehealth Rehab and Residential Care failed to ensure such. The citation specifically describes an employee who “did not receive training and education on the use of assistive devices,” and who provided a walker to resident but did not assist that resident during ambulation in accordance with the resident’s care plan. The resident consequently fell and sustained “a laceration and skin tear.” A plan of correction undertaken by the facility included the re-education of the employee in question.

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A nursing home in Oswego, New York has received $46,000 in fines since 2013.

Pontiac Nursing Home has received 37 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on April 30, 2021. The facility has additionally received three fines totaling $46,000 since 2013. The Oswego nursing home’s citations resulted from a total of six surveys by state inspectors. The deficiencies they describe include the following: Continue reading

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The New York nursing home has received citations for medication errors and pressure ulcer care.

Salamanca Rehabilitation & Nursing Center has received received 68 citations for violations of public health code between 2017 and 2021, according to health records accessed on March 19, 2021. The Salamanca 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 ensure that residents were protected from the use of unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing home residents’ drug regimens “must be free from unnecessary drugs.” An August 2019 citation found that Salamanca Rehabilitation & Nursing Center failed to ensure such. The citation states specifically that one resident was kept on an antibiotic regimen “without adequate indications for its use.” In an interview, the facility’s Assistant Director for Nursing said that the underlying symptoms, “a single episode of burning upon urination” and an increase in temperature, did not meet the nursing home’s “criteria for antibiotic use.” A plan of correction undertaken by the facility included a review of its antibiotics policies and procedures.

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A nursing home in Cheektowaga, New York has received 27 health citations in the last four years.

Elderwood at Cheektowaga suffered 18 confirmed COVID-19 deaths as of January 23, 2021, according to state records. The facility has also received 27 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 23, 2020. The Cheektowaga 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 adequately prevent and control infection. Under Section 483.80 of the Federal Code, nursing homes are required to create and maintain an infection 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 November 2019 citation found that Elderwood at Cheektowaga failed to ensure such. The citation states specifically that in one resident unit, dirty bed linens “were placed directly on the floor without a protective barrier,” and that in another unit, oxygen tubing “was observed directly on the floor during multiple observations,” all in contravention of facility policy. A plan of correction undertaken by the facility included the discarding of the tubing and the re-education of the staff member who placed dirty linens on the floor.

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The New York nursing home received 36 health citations in the last four years.

Newfane Rehab & Health Care Center suffered 21 confirmed and 7 suspected 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 Newfane 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 accidents. Under Section 483.25 of the Federal Code, nursing homes must provide every resident with “adequate supervision and assistance devices to prevent accidents.” A September 2019 citation found that Newfane Rehab & Health Care Center failed to ensure such. The citation states specifically that a resident who was care-planned to receive check-ups every 15 minutes and one-to-one supervision when off-unit was “observed wandering off the unit with no 1:1 staff or 15-minute check.” A plan of correction undertaken by the facility included the updating of the resident’s care plan and a monthly review of weekly wander-guard system summaries.

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The New York nursing home has also received a fine of $10,000.

Elderwood at Lockport received 31 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 8, 2021. The facility also received a fine of $10,000 in February 2020 in connection to violations of unspecified health code provisions. The Lockport 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 steps to prevent accidents. Section 483.25 of the Federal Code requires nursing homes to keep resident environments as free as possible of accident hazards and to provide residents with adequate supervision to prevent accidents. An October 2019 citation found that Elderwood at Lockport failed to ensure such. The citation states specifically that one resident who was documented for one-to-one supervision “was left unattended in a common area,” and subsequently sustained a fall and a redacted medical injury. In an interview, the facility’s administrator said the resident was left unattended in a chair because they were sleeping, and their wasn’t any violation of the resident’s care plan. A plan of correction undertaken by the facility included a review of guidelines for one-to-one supervision of residents.

Corning Center for Rehabilitation and Healthcare suffered 28 confirmed COVID-19 deaths as of January 2, 2021, according to state records. The facility has also received 33 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 2, 2020. The Corning 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 adequately protect residents from accident hazards. Under Section 483.25 of the Federal Code, nursing home residents are required to be provided with an environment that is “as free of accident hazards as is possible.” A March 2018 citation found that Corning Center for Rehabilitation and Healthcare failed to ensure such when it served sliced turkey to a resident “who was on a mechanical soft diet with ground meats.” In an interview, one of the facility’s Licensed Practical Nurses stated that “according to the tray ticket, the resident should have received ground turkey, not sliced.” The facility’s Director of Food Services stated in an interview that “someone on the tray line must have made a mistake.” A plan of correction undertaken by the facility included the re-education of dietary staff.

2. The nursing home did not implement adequate measures to prevent and control infection. Under Section 483.80 of the Federal Code, nursing home facilities must “establish and maintain an infection prevention and control program designed to… help prevent the development and transmission of communicable diseases and infections.” A March 2018 citation found that Corning Center for Rehabilitation and Healthcare failed to ensure such. The citation states specifically that in connection to one resident, “there was improper incontinence care and lack of glove changing and handwashing,” and that shower stretchers used by the facility for several residents “were not clean.” A plan of correction undertaken by the facility included the cleaning of shower stretchers and the re-education of the Certified Nursing Assistant who failed to provide proper incontinent care.

The Riverside suffered 48 confirmed and 17 presumed COVID-19 deaths as of December 26, 2020, according to state records. The nursing home has also received 53 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on December 26, 2020. The New York 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 protect residents from abuse. Under Section 483.12 of the Federal Code, nursing home residents have a right to freedom from abuse and neglect. A June 2020 citation found that The Riverside failed to ensure such. The citation states specifically that a resident who had “dementia and a history of physical aggression” participated in four altercations with other residents after the facility transferred her to a new unit. According to the citation, the facility did not put interventions in place to address this resident’s behavior and to protect other residents in the unit. It goes on to state that one altercation resulted in a laceration to the crown of another resident’s head; a subsequent altercation resulted in the aggressor’s transfer to the hospital for evaluation. A plan of correction undertaken by the facility included the review and revision of her care plan.

2. The nursing home did not provide adequate treatment for dementia. Section 483.40 of the Federal Code requires that nursing homes provide residents suffering from dementia with “appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.” A June 2020 citation found that The Riverside failed to provide such. The citation states specifically that the facility did not take individualized interventions in response to a resident’s “increasing dementia-related behaviors that occurred after a room change,” specifically, the resident’s instigation of physical altercations with other residents, including hitting one over the head with a footrest. A plan of correction undertaken by the facility included the creation of a person-centered care plan for the resident.

A new report by the Long Term Care Community Coalition highlights “no harm” deficiencies in nursing home facilities.  “No Harm” deficiencies are citations that find a nursing home violated health code provisions in a manner that did not cause residents harm. The LTCCC argues that many such citations in fact reflect harm done to nursing home residents, and more broadly reflect systemic failures in elder care facilities. But since the citations rarely if ever result in financial penalties, the LTCCC suggests, nursing homes have no incentive to address these systemic deficiencies. The report specifically discusses citations at nursing homes in four states: Continue reading

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