Articles Posted in Falls & Fractures

Penn Yan Manor Nursing Home has received 14 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The Penn Yan nursing home’s citations resulted from a total of two surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately supervise residents. Section 483.25 of the Federal Code requires nursing homes to provide residents with “adequate supervision and assistance devices to prevent accidents.” A November 2019 citation found that Penn Yan Manor Nursing Home failed to ensure such for one resident. The citation states specifically that the resident did not receive adequate supervision to prevent her from eloping from the facility undetected and falling outside, after which her care plan “was not revised to include an actual elopement.” The citation goes on to describe the nurse turning off an alarm at the nurse’s station, after which the resident exited the facility undetected, and later being found sitting on the ground by a staffer from a “neighboring facility,” who brought her back. In an interview, the nurse in question said “she thought she was resetting the alarm at the nurses’ station when she turned it off.” A plan of correction undertaken by the facility included the re-education of staff on the nurses’ station alarm system.

2. The nursing home did not adequately prevent medication errors. Section 483.45 of the Federal Code stipulates that nursing homes must ensure their medication errors rates do not meet or exceed five percent. A November 2019 citation found that Penn Yan Manor Nursing Home did not ensure such for two residents. The citation states specifically that one resident’s eye drops “were administered in both eyes instead of one eye,” and the other “had a medication ordered after meals that was given over an hour after meals.” A plan of correction undertaken by the facility included the re-education of nurses on medicine administration and the disciplining of one nurse.

Diamond Hill Nursing and Rehabilitation Center has received 55 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on July 31, 2020. The facility has also received four fines totaling $22,000 over findings that it violated health code provisions regarding quality of care, staff mistreatment of residents, abuse, and more. The Troy nursing home’s citations resulted from a total of seven surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not employ proper infection control protocols. Section 483.80 of the Federal Code stipulates that nursing homes must provide a safe and sanitary environment for residents through the creation and maintenance of an infection prevention and control program. A May 2018 citation found that Diamond Hill Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that the nursing home did not develop a Legionella Water Management Plan per regulations; that it failed to ensure oxygen tubing that had rested on the floor was not given to a resident to be used; that it did not ensure urinary catheter tubing was kept off the floor; and that staff members who had not received a flu vaccination properly wore face masks. A plan of correction undertaken by the facility included the review and updating of the Legionella Water Sampling and Management Plan, and the review and revision of policy concerning the use of masks by staff and volunteers who had not received the flu vaccination.

2. The nursing home did not employ adequate accident prevention measures. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with an environment as free as possible of accident hazards. A May 2018 citation found that Diamond Hill Nursing and Rehabilitation Center did not ensure such for one resident. The citation states specifically that the resident neglected to identify and report the resident’s “use of the remote control to raise her bed to the highest position as a potential risk for injury.” The citation goes on to state that the resident “was found on the floor next to her bed,” and that the bed was not in its lowest position. As a result, the resident sustained “a left distal femoral fracture and fractures of the right distal tibia (shinbone) and fibula (calf bone),” according to the citation. A plan of correction undertaken by the facility included the updating of the resident’s care plan, with the resident’s family’s agreement, to keep the remote out of the resident’s reach.

Richmond Center for Rehabilitation and Specialty Healthcare received 19 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on July 22, 2020. It has also received four enforcement actions resulting in cumulative fines of $42,000, connected to findings that it violated health code provisions concerning resident behavior, investigations, accidents, and more. The Staten Island 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 properly mitigate the risk of infection. Section 483.80 of the Federal Code requires nursing homes to create and maintain programs to prevent and control infection. A January 2019 citation found that Richmond Center for Rehabilitation and Specialty Healthcare did not ensure such. The citation specifically describes a respiratory therapist who performed suctioning on a resident without practicing proper hand hygiene. According to the citation, the therapist put on a pair of gloves and started suctioning the resident without first washing his hands. In an interview, the therapist “acknowledged that he didn’t wash hands prior to donning gloves and performing suctioning of the resident.” A plan of correction undertaken by the facility included the counseling and re-in-servicing of the respiratory therapist.

2. The nursing home did not take adequate measures to prevent accidents. Section 483.25 of the Federal Code requires nursing homes to provide residents with an environment as free as is possible from accident hazards. A June 2017 citation found that Richmond Center for Rehabilitation and Specialty Healthcare failed to ensure such. The citation states specifically that “a portion of the hand rail outside of the 2nd floor dining room was observed missing, exposing a portion of metal.” Another observation of a 3rd floor dining area bathroom found that “the handrail to the right side, behind the toilet seat” had a “sharp exposed metal plate.” In an interview, the facility’s Director of Maintenance said that “no one had reported any issues with the metal plate behind the toilet and that the sharp plate would be covered to prevent resident injury.”

Elderwood at Waverly suffered 19 fatalities from Covid-19 as of July 18, 2020, per state records. The nursing home also received 17 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 20, 2020. It was additionally the recipient of a 2019 fine in connection to findings in a 2018 survey that it violated unspecified health code provisions. The Waverly nursing home’s citations resulted from a total of six surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not properly supervise residents to prevent accidents. Section 483.25 of the Federal Code requires nursing homes to ensure resident environments are kept as free as possible of accident hazards, and that residents received “adequate supervision and assistance devices to prevent accidents.” A January 2019 citation found that Elderwood at Waverly failed to ensure residents received an adequate level of supervision with the use of assistance devices. The citation specifically describes a resident with “moderate cognitive impairment” who required the assistance for transfers and walking. “The resident utilized a wheelchair and walker, was not steady when moving fro a seated to standing position and for surface to surface transfers,” according to the citation, which goes on to describe an instance in which the resident was observed “self-propelling from the dining room to her room using doorways and handrails to assist” and with her feet under her wheelchair’s leg rest foot plates; it also describes another instance in which she stood from her wheelchair to move to the other side of a table in the dining room, and another in which she self-propelled with her feet under her wheelchair’s leg rests. In an interview, the facility’s Director of Therapy stated that “any resident who self-propelled in a wheelchair with their legs and feet should not have leg rests on the chair due to the risk to fall and impeding mobility.” A plan of correction undertaken by the facility included a revision of the resident’s care plan concerning the use of leg rests.

2. The nursing home did not protect residents from abuse. Section 483.12 of the Federal Code requires nursing homes to protect each resident’s right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” An October 2018 citation found that Elderwood at Waverly failed to ensure such. The citation specifically describes a resident who “was observed on video being hit by facility staff.” According to the citation, a Registered Nurse “bent to kiss the resident on her forehead” after administering medication, at which point the resident struck theRN in the face, and the RN “responded by grabbing and slapping the resident’s left arm.” A plan of correction undertaken by the facility included the termination of the RN.

The Paramount at Somers received 28 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 7, 2019. The facility was also the subject of a 2012 fine of $14,000 in connection to alleged violations of New York Code sections concerning nursing home residents’ right to be notified of their rights, rules, services, and charges; administrative practices and procedures; and nursing home facility medical directors. The Somers nursing home’s citations resulted from a total of six inspections by state surveyors. The deficiencies they describe include the following:

1. The facility did not ensure residents were provided with an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to maintain an environment as free as possible from accident hazards, with adequate supervision and assistive devices to prevent residents from sustaining accidents. An October 2018 citation found The Paramount did not provide frequent room checks and supervision of a resident who “had numerous falls in her room without injury.” The citation states that the resident’s care plan included frequent room checks as an intervention method to prevent falls, but such checks were not implemented, and the facility “did not determine if frequent checks were conducted or a potential contributory factor to the accident.”

2. The nursing home did not take adequate steps to prevent and control infection. Section 483.80 of the Federal Code stipulates that nursing home facilities must “establish and maintain an infection prevention and control program” that creates a safe and sanitary environment for residents. A February 2019 citation found that facility did not ensure staff followed proper hand hygiene so as to prevent infection. An inspector specifically observed a failure by staff to perform proper hand hygiene while feeding residents at mealtime and assisting residents with feeding. The inspector also observed a staff member change the dressing on a resident’s wound and then lift a “sterile dressing instrument package” without putting on new gloves or washing her hands after discarding the resident’s soiled wound dressing.

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.

Contact Information