Falls & Fractures

March 24, 2020

Westchester Center for Rehabilitation and Nursing Cited for Fall, Ulcer

by Law Offices of Thomas L. Gallivan, PLLC

Westchester Center for Rehabilitation and Nursing received 40 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. That figure is eight greater than the statewide average of 32. The Mount Vernon nursing home’s citations resulted from a total of three inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not meet quality of care standards. Section 483.25 of the Federal Code states that nursing homes must ensure that residents “receive treatment and care in accordance with professional standards of practice” and based on comprehensive assessments of each individual. According to a July 17, 2019 inspection, the nursing home did not ensure proper treatment and care for three residents. An inspector found that one resident did not receive “timely treatment and care for complaints of pain” resulting from their fall from a lift; another did not receive timely treatment and care for a bedsore/pressure ulcer on their left heel; and a third was not provided prompt medication, per a physician’s orders, for their “critically elevated potassium levels.” The citation describes these failures as resulting in the “potential to cause more than minimal harm” to residents.

March 21, 2020

Sapphire Nursing at Meadow Hill Cited, Fined $72,000

by Law Offices of Thomas L. Gallivan, PLLC

Sapphire Nursing at Meadow Hill received 42 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 facility has also been the subject of a 2011 fine of $72,000 in connection to findings during a 2009 inspection that it violated health code provisions regarding mistreatment and neglect, pressure ulcers, resident dignity, resident well-being, nurse aid competency, and administrative practices and procedures. The Newburgh 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 residents were free from significant medication errors. Section 483.45 of the Federal Code ensures nursing home residents the right to be “free of any significant medication errors.” A May 2019 citation found that Sapphire Nursing at Meadow Hill did not ensure its residents were free of such. An inspector specifically found that one Licensed Practical Nurse “did not administer medications prescribed by the physician” to 12 residents. A plan of correction undertaken by the facility included the suspension of that LPN, whose employment with the facility later ended. The citation states that this deficiency had the “potential to cause more than minimal harm.”

February 22, 2020

Terence Cardinal Cooke Health Care Center Cited for Fall, Abuse

by Law Offices of Thomas L. Gallivan, PLLC

Terence Cardinal Cooke Health Care Center received 34 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 13, 2020. The facility has also been the subject of a 2011 fine of $2,000 in connection to findings during a 2010 inspection that it violated health code provisions regarding quality of care. The Manhattan 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 ensure residents an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing homes must provide residents an environment as free as possible from accident hazards, and which also has adequate staff supervision to prevent accidents. A February 2018 citation found that Terence Cardinal Cooke Health Care Center did not provide one resident with necessary supervision to prevent an accident. The citation notes that the resident had been identified as at high risk for fall and injury, and that her comprehensive care plan documented that staff would monitor the resident directly when the resident was at the nursing station. In spite of this, according to the citation, the resident sustained a fall and injury at the nursing station. A Licensed Practical Nurse stated in an interview that she had not assigned anyone to monitor the resident, and that none of the six Certified Nursing Assistants on the unit witnessed the fall. In an interview, the facility’s Director of Nursing stated of the resident’s care plan documentation for monitoring while at the nursing statement, “it has a greater chance that staff will see the resident more often, and does not mean that the resident must be on Line of Sight.”

February 21, 2020

Northern Manor Geriatric Center Cited for Fall, Fined $20,000

by Law Offices of Thomas L. Gallivan, PLLC

Northern Manor Geriatric Center received 34 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 13, 2020. The facility has also been the subject of a 2016 fine of $10,000 in connection to findings during a 2014 inspection that it violated health code provisions regarding pressure sores; and another 2016 fine of $10,000 in connection to findings during a 2015 inspection that it violated health code provisions regarding pressure sores. The Nanuet 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 take adequate steps to prevent residents from sustaining falls. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents an environment “as free of accident hazards as is possible” and with “adequate supervision and assistance devices to prevent accidents.” A January 2019 citation found that Northern Manor Geriatric Center did not ensure effective assistance devices were provided to residents who required them. The citation states specifically that in connection to a resident’s fall while being transferred from their bed to their wheelchair via a mechanical lift using a sling, the nursing home did not ensure “the sling was laundered according to the manufacture’s [sic] instructions,” that the facility’s staff had been trained to assess the sling’s functionality before using it, and that the nursing home had a system to inspect such slings. The citation notes that the residents sustained a redacted injury from the fall, and was sent to the hospital.

January 8, 2020

Forest Hills Care Center Cited over Neglect, Fall

by Law Offices of Thomas L. Gallivan, PLLC

Forest Hills Care Center received 18 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The facility was also the subject of a 2018 fine of $12,000 in connection to unspecified findings in a December 2017 survey. The Forest Hills nursing home’s citations resulted from a total of three inspections by state authorities. The violations they describe include the following:

1. The nursing home did not take adequate measures to protect residents from neglect. Section 483.12 of the Federal Code requires nursing homes to protect residents from “abuse, neglect, misappropriation of resident property, and exploitation.” A December 2017 citation found that Forest Hills Care Center did not ensure a resident’s right to freedom from neglect. The citation specifically found that a Certified Nursing Assistant “willfully neglected to implement” a resident’s Comprehensive Care Plan requirement for the resident to be transferred from their bed to their wheel chair by two persons and the use of a Hoyer Lift. As a result of this failure, the resident fell while being transferred and sustained an injury to their hip.

January 3, 2020

Silvercrest Nursing Home Cited for Fall

by Law Offices of Thomas L. Gallivan, PLLC

Silvercrest received 19 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 13, 2019. The Jamaica nursing home’s citations resulted from a total of four inspections by state authorities. The violations they describe include the following:

1. The nursing home did not take adequate measures to prevent residents from sustaining falls. Section 483.25 of the Federal Code requires nursing homes to ensure that residents receive supervision to prevent them from sustaining accidents. According to a September 2018 citation, Silvercrest did not adequately supervise one resident, resulting in the resident falling. An inspector specifically found that the resident, who had been “assessed as a high risk for falls,” was left unattended in one of the facility’s hallways, and sustained a fall. When the resident was found by staff, she was observed suffering from “pain and swelling of the left shoulder” and transferred to a local hospital for examination.

December 9, 2019

The Grove at Valhalla Rehabilitation and Nursing Center Cited for Falls

by Law Offices of Thomas L. Gallivan, PLLC

The Grove at Valhalla Rehabilitation and Nursing Center received 27 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 29, 2019. The Valhalla 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 adequately implement an infection prevent and control system. Under Section 483.80 of the Federal Code, nursing home facilities must create and maintain infection prevention and control protocols that are “designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” An August 2018 citation found that the facility did not properly ensure its staff undertook adequate hand hygiene measures “to prevent cross contamination and the spread of infection” in connection to one resident. The citation states specifically that during a wound observation of the resident, who was at risk of developing a pressure ulcer, an inspector observed a Licensed Practical Nurse “his bare hands to reposition the resident in bed, in addition to pulling the bedside curtain to maintain privacy.” Then, without sanitizing his hands, the nurse in question put on a pair of of gloves with which he opened a saline solution bottle, poured the solution on gauze pads, and cleaned the resident’s wound. According to the citation, the nurse continued wearing “the soiled gloves” as he went on to perform several other activities that included touching the wound. The citation states that this conduct had the “potential to cause more than minimal harm.”

2. The nursing home did not properly implement its abuse and neglect investigation and reporting policies. Section 483.12 of the Federal Code requires nursing homes to develop and implement policies and procedures that prohibit and prevent abuse and neglect, and that provide for the investigation of abuse and neglect allegations. A November 2018 citation found that the nursing home failed to thoroughly investigate a resident’s unwitnessed fall, and to timely report the incident to state authorities in order to rule out the possibility of abuse, neglect, or mistreatment. The citation states further that the nursing home failed to report and investigate a second fall sustained by the resident. In response to the citation, the nursing home initiated an investigation into one of the incidents, and stated its intention to report the incident and the investigation’s results to state health authorities.

November 24, 2019

The Citadel Rehab and Nursing Center Cited for Systemic Accident Hazards

by Law Offices of Thomas L. Gallivan, PLLC

The Citadel Rehab and Nursing Center at Kingsbridge received 19 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. Those citations include two that were found to cause immediate jeopardy to resident health, and one that authorities say reflected “a severe, systemic deficiency.” The Bronx 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 ensure it provided an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide residents with an environment as free as possible from accident hazards, and with proper supervision and assistive devices to prevent accidents. An August 2016 citation states that an inspector observed more than 50 beds with siderails whose measurements “exceeded the FDA recommendation that spaces between the bed siderail bars should be no larger than 4 3/4 inches.” While the Department of Health inspector found that this deficiency had so far not resulted in actual harm, it had “the potential for more than minimal harm that was immediate jeopardy and substandard quality of care.”

November 17, 2019

Jeanne Jugan Residence Cited for Fall, Fined

by Law Offices of Thomas L. Gallivan, PLLC

Jeanne Jugan Residence received 19 citations for violations of public health laws between 2015 and 2019, according to records provided by the New York State Department of Health and accessed on November 14, 2019. The Bronx nursing home also received a Federal Civil Money Penalty of $8,518.25 for citations found on a March 9, 2018 survey, according to the Long Term Care Community Coalition. Federal Civil Money Penalties are one of several remedies state and federal authorities are empowered to assess when nursing home facilities are found to fall short of minimum health and safety standards. Jeanne Jugan Residence’s 19 citations result from three inspections by state inspectors. The violations they describe include the following:

1. The facility did not ensure an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities must provide an environment as free as possible from accident hazards, and with adequate supervision and assistive devices to ensure that residents do not sustain accidents. A March 9, 2018 inspection found that Jeanne Jugan Residence’s staff failed to adequately train and supervise a Certified Nursing Assistant to ensure that a resident’s care plan was implemented in such a manner that would prevent them from sustaining an injury. The resident specifically required the assistant of two persons “when applying a sling for stand up lift while sitting in bed, and floor mats were to be at bedside to prevent injury from falls.” The inspection found that the CNA tried to assist the resident without a second staffer’s assistance, and apparently without floor mats in place. As a consequence of this lapse, the resident fell from their bed and sustained harm to their clavicle.

October 29, 2019

Senate Releases List of 400 Troubled Nursing Homes

by Law Offices of Thomas L. Gallivan, PLLC

Senators released a list of 400 nursing homes with a ‘persistent record of poor care,’ according to the federal legislators. These nursing homes are not included in the federal government’s “special focus facilities” a list of nursing homes released by the government each year indicating poor care and unsafe conditions. According to the Senators, the list of 400 facilities is “virtually indistinguishable” from special focus facilities and the elder care facilities are not all lumped together only because a 2014 law imposed a cap on the number of so-called special focus facilities. Consequently, this left 400 facilities subject to heightened government scrutiny without public knowledge.

According to the Centers for Disease Control and Prevention, approximately 1.3 million Americans are nursing home residents at 15,600 facilities across the country. The federal government identified 3 percent of these nursing homes as problematic in April. In New York, these nursing homes include New Roc Nursing and Rehabilitation Center in Rochester, The Knolls in Valhalla, and Cayuga Ridge Extended Care in Ithaca, according to LoHud.com. In addition to these nursing homes, fourteen other New York long-term care facilities were included in the list of 400 released by the Senate.