Articles Posted in Falls & Fractures

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.

Beechwood Homes suffered 21 fatalities from Covid-19 as of June 29, 2020, per state records. The nursing home also received 33 citations finding it violated public health code between 2016 and 2020, according to health records accessed on June 30, 2020, including one citation over findings of infection prevention measures. The Getzville 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 take adequate measures to ensure residents were protected from 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” that helps mitigate communicable diseases and infections. A May 2019 citation found Beechwood Homes failed to do so. The citation states specifically that the nursing home failed to perform “routine Legionella culture sampling and analysis at intervals” that did not exceed 90 days in its first year of testing and yearly afterward. According to the citation, the citation affected both of the nursing home’s resident use buildings. In an interview, the facility’s Director of Plant Operations said “he was not aware of the quarterly testing requirement for the buildings’ portable water supply” and that the nursing home had conducted two samplings in a redacted year. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Absolut Center for Nursing and Rehabilitation at Aurora Park suffered 30 deaths from Covid-19 as of May 24, 2020, per state records. The nursing home also received 69 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on May 26, 2020. The facility has additionally received three enforcement actions: a 2017 fine of $10,000 in connection to findings in a 2016 inspection that it violated health code provisions regarding accidents; a 2016 fine of $10,000 in connection to findings in a 2015 inspection that it violated health code provisions regarding pressure sores; and a 2016 fine of $4,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding accidents and administrative matters. The East Aurora nursing home’s citations resulted from a total of six inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not take adequate infection control measures. Section 483.80 of the Federal Code stipulates that nursing homes must establish and implement an infection prevention and control program. A September 2018 citation found that Absolut Center for Nursing and Rehabilitation at Aurora Park did not ensure that its Legionella Management Program included an annually updated environmental assessment and management plan. The citation states that this deficiency affected all three of the facility’s resident use buildings; that about 25 months had passed since the updating of a document titled Environmental Assessment of Water Systems in Healthcare Settings; and that about 22 months had passed since the updating of documents titled Legionnaires Plan and Policy and Risk Management Plan for Legionella Control. A plan of correction undertaken by the facility included the establishment of an annual review of the policy in question.

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Yonkers Gardens Center for Nursing 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 April 24, 2020. The Yonkers 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 measures to prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments that are as free as possible from accident hazards, and that they provide every resident with adequate supervision and assistance to prevent accidents. A May 2019 citation found that Yonkers Gardens Center for Nursing and Rehabilitation did not ensure such. The citation specifically describes a resident who was cognitively impaired and depended on the help of one staffer for toileting, hygiene, and dressing. It goes on to describe an interview in which the resident said that due to a broken commode frame in his bathroom, he had been using a public restroom in the hall near his room, and “had fallen several times in his room and once in the lavatory.” A plan of correction undertaken by the facility included the placement of the left side of the commode frame in the resident’s bathroom, and the evaluation of the resident by a physical therapist.

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Martine Center for Rehabilitation received 30 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. The White Plains 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 ensure an environment free of accident hazards. Section 483.25 of the Federal Code requires nursing home facilities to provide an environment as free as possible from accident hazards, and with adequate supervision and assistive devices to prevent accidents. A June 28, 2018 inspection found that a resident who suffered a fall resulting in an injury had not been provided with non-skid socks, as her plan of care directed. She was considered “at risk for falls secondary to impaired mobility and functional status,” and after a 2017 fall, staff members were directed to ensure she wore non-skid socks at all times. After a later incident in which she fell while trying to go to the bathroom, an inspector found, the subsequent investigation “did not address whether the resident was wearing the appropriate footwear” or if staff were implementing her plan of care properly to ensure such. The inspector found that this lapse resulted in the “potential to cause more than minimal harm.”

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Huntington Hills Center for Health and Rehabilitation received 26 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 3, 2020. The facility has also received three fines: a 2019 fine of $10,000 in connection to findings in a 2019 inspection that it violated unspecified health code provisions; a 2019 fine of $10,000 in connection to findings in a 2018 inspection that it violated unspecified health code provisions; and a 2016 fine of $12,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding accident supervision and dietary services. The Melville 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 ensure residents were protected from neglect involving a fall. Section 483.12 of the Federal Code provides nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A February 2019 citation found that Huntington Hills Center for Health and Rehabilitation did not ensure such for one resident. The citation states specifically that the resident was transferred by a Certified Nursing Assistant and a Licensed Practical Nurse from the floor to their bed without those individuals “reporting to, or ensuring that the resident was assessed by, a Registered Nurse (RN), Nurse Practitioner (NP) or a physician (MD) after an unwitnessed fall.” The citation states further that after the fall, the resident in question experienced pain and was not able to bear weight to their right leg. No physician or NP was notified, according to the citation, until seven hours after facility staff noted a change in the resident’s condition, and the resident did not receive an assessment by a clinician “for at least 23 hours after the fall,” after which they were transferred to the hospital where a fracture was discovered. The citation states that these deficiencies resulted in “actual harm” to the resident.

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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.

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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.”

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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.”

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