Articles Posted in Infection

Haym Solomon Home for the Aged received 25 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 21, 2020. The Brooklyn 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 adequately protect residents free from neglect. Section 483.12 of the Federal Code requires nursing home to ensure residents’ “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A June 2018 citation found that Haym Solomon Home for the Aged did not protect one of its residents from neglect. The citation states specifically that one of the facility’s Certified Nursing Assistants did not properly supervise a resident during a shower, in accordance with the resident’s plan of care. According to the citation, “The CNA left the resident alone in the shower room, and the resident fell from the shower chair. After the resident fell, the CNA did not call for the assistance of a nurse, picked the resident up alone, and placed the resident back onto the shower chair.” The citation notes that the resident’s plan of care required the resident to receive shower assistance from two persons, and that the resident experienced a small cut and redness on parts of their skin as a result. The citation notes that “actual harm has occurred” as a result of this incident.

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Hopkins Center for Rehabilitation and Healthcare received 23 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 21, 2020. The facility has also been the subject of a 2015 fine of $10,000 in connection to findings it violated health code provisions regarding residents’ right to formulate advance directives; and a 2012 fine of $4,000 in connection to findings it violated health code provisions regarding accidents and administration. The Brooklyn 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 implement adequate measures to prevent and control infection. Section 483.80 of the Federal Code states that nursing homes must “establish and maintain an infection prevention and control program” that provides residents a “safe, sanitary and comfortable environment.” An August 2019 citation found that the nursing home did not ensure the maintenance of infection control practices, specifically finding that residents’ oxygen tubing made contact with the floor “on multiple occasions”; that a Certified Nursing Assistant entered the room of a resident on contact precautions “without wearing a gown and gloves”; and a Registered Nurse touched a resident’s head and bedding while wearing gloves, then connected a feeding tube without conducting hand hygiene or putting on clean gloves. The citation described these deficiencies as having the “potential to cause more than minimal harm.”

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Hollis Park Manor Nursing Home received 39 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 10, 2020. The Hollis 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 implement adequate (bedsore) pressure ulcer care. Section 483.25 of the Federal Code requires nursing homes to provide residents with a level of treatment and services that prevents the infection of pressure ulcers. An August 2018 citation found that a resident did not receive the necessary care and treatment to prevent the infection of a sacral pressure ulcer. An inspector specifically observed that “there was no dressing observed to the sacral area” on the resident’s ulcer” during care. In an interview, a Certified Nursing Assistant stated that he had removed the dressing while changing the resident; in another interview, a Licensed Practical Nurse stated that CNAs “are not to remove any dressings,” and to inform nurses if dressings become soiled or fall off the wound.

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Bezalel Rehabilitation and Nursing Center received 25 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 9, 2020. The Far Rockaway 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’ drug regimens were free from unnecessary psychotropic medications. Section 483.45 of the Federal Code requires that nursing homes keep residents’ drug regimens free from the unnecessary use of any drugs that affect “brain activities associated with mental processes and behavior. A June 2019 citation found that Bezalel Rehabilitation and Nursing Center did not ensure a resident properly received gradual dose reductions to discontinue the use of a psychotropic medication. The citation states specifically that the resident was admitted to the nursing home already receiving the medication, but the facility did not attempt a gradual dose reduction, and “there was no evidence that the resident displayed any mood or behavioral symptoms that warranted continued use of the medication without a GDR attempt.” The citation states further that the nursing home did not attempt, before the resident was admitted, to confirm their psychiatric history.

2. The nursing home did not maintain an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with an environment as free as possible from accident hazards, and with adequate supervision to ensure that residents do not experience accidents. A June 2016 citation found that the nursing home did not take adequate accident prevention measures with respect to one resident who had planned monitoring for swallowing difficulty and aspiration precautions. According to these citations, the precautions included “being observed while eating, sitting upright while eating and for at least 30 minutes after eating, never eat in bed and if resident experiences coughing or secretions, during or without meal hold the feed till totally clear.”

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NYS Veterans Home in NYC received 31 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 facility was also the subject of three fines from the Department of Health: a 2016 fine of $2,000 in connection to findings the facility did not comply with health code provisions concerning accident hazards; a 2015 fine of $10,000 in connection to findings it did not comply with health code provisions regarding quality of care; and a 2010 fine of $6,000 in connection to findings it did not comply with health code provisions regarding social services, accidents, and administrative procedures. The Jamaica 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 adequately ensure the prevention and control of infection. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program” that provides residents with a safe and sanitary living environment. A January 2018 citation found that NYS Veterans Home in NYC did not ensure its staff performed proper hand hygiene practices. An inspector specifically observed one of the facility’s Licensed Practical Nurses “handling sterile supplies with soiled gloves.” According to the citation, the LPN, while wearing gloves, put a sterile drape on the resident’s chest, then moved the resident’s garbage clan closer to her. She was then observed removing the gloves and putting on a new pair of gloves, but did not wash her hands or otherwise clean them with an alcohol-based solution. The citation states that this deficiency resulted in the “potential to cause more than minimal harm.”

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Chapin Home for the Aging received 17 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 Jamaica nursing home’s citations resulted from a total of four inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not protect residents from abuse and neglect. Under Section 483.12 of the Federal Code, nursing homes must ensure their residents’ “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A June 2019 citation found that Chapin Home for the Aging failed to comply with this section in an instance in which one resident was “observed in his room with his wheelchair leg rest in his hand, raised above” another resident, who was observed in bed “with multiple lacerations and… covered with blood.” The latter resident had lacerations on his scalp and his ear, as well as “excoriations” on his left shoulder and left upper arm. The resident was transferred to the local hospital, where he received 20 medical staples. The citation found that this deficiency on the nursing home’s part resulted in “actual harm.”

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Park Terrace Care Center received 30 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 2017 fine of $2,000 in connection to findings in a December 2016 survey that it did not provide adequate pressure ulcer care. The Rego Park nursing home’s citations resulted from a total of four inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not provide adequate treatment and services for residents’ pressure ulcers and bedsores. Section 483.2 of the Federal Code requires nursing homes to residents persons who enter without pressure sores from developing them unless their condition renders such unavoidable; and that residents with pressure sores receive treatment and services adequate to promote their healing. A December 2016 citation found that Park Terrace Care Center did not properly assess and evaluate a resident who was admitted to the facility “with intact skin and a discoloration” on their left foot. The resident subsequently developed an “unstageable pressure ulcer,” according to the citation, which goes on to state that whereas the resident’s plan of care provided for the wearing of a left air boot “at all times after the pressure ulcer was identified,” this provision was not followed by staff. The citation states that this deficiency in the facility’s treatment and care resulted in “actual harm” to the resident.

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Park Gardens Rehabilitation & Nursing Center received 38 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 21, 2019. Those citations number six more than the statewide average of 32. The Bronx 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 ensure its residents’ drug regimens were free from unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing homes must maintain “each resident’s drug regimen… free from unnecessary drugs,” going on to clarify that “unnecessary” refers to any drug used in excessive dosage, for excessive duration, without adequate monitoring or indications, and/or in the presence of adverse consequences. A March 2017 citation found that Park Gardens Rehabilitation and Nursing Center failed to comply with this section in two separate capacities. In one, the facility did not provide “adequate monitoring” of a diabetic resident who had recently received an increase in their insulin dosage, so as to figure out whether the increase was effective or yielded any ill effects. Separately, the citation notes, the nursing home increased another resident’s dosage of an unidentified medication “without documentation for the reason of the increase.” The citation states that these failures resulted in the “potential to cause more than minimal harm” to residents.

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The Emerald Peek Rehabilitation and Nursing Center received 31 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The Peekskill nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing did not provide treatment and services of a degree adequate to ensure prevention and/or healing of pressure ulcers. Section 483.25 of the Federal Code requires nursing home facilities to offer residents “care, consistent with professional standards of practice, to prevent pressure ulcers” from developing and to heal existing pressure ulcers. A January 2019 citation found “no evidence” that when a resident developed a pressure ulcer, the facility undertook actions to get rid of risk factors connected to pressure ulcer development. In response to the citation, the facility implemented a plan of correction that included weekly risk assessment and intervention audits to ensure the proper execution of preventative measures for pressure ulcer development.

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Hamilton Park Nursing and Rehabilitation Center received 9 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 22, 2019. The Brooklyn nursing home’s citations resulted from a total of two inspections by state surveyors, in November 2016 and May 2018. The deficiencies they describe include the following:

1. The nursing home did not take adequate steps to care for prevent pressure ulcers and bedsores. Under Section 483.25(c) of the Federal Code, nursing homes must provide a level of care that prevents residents who enter without pressure sores from developing them unless their condition renders such unavoidable; and that residents suffering from pressure sores must receive necessary and adequate care. A November 2016 citation describes the failure by Hamilton Park Nursing & Rehabilitation Center to follow orders to provide a resident with “dry protective dressing on a sacral ulcer.” The resident was admitted to the facility with three unhealed pressure ulcers, according to the citation, and a physician ordered that one of them be treated in part with dry protective dressing. An inspector observed the resident without the required dressing, and spoke to a staff nurse, who “confirmed that she was not informed that the necessary dressing was missing and needed to be replaced.” The inspector determined in an interview with a Certified Nursing Assistant that the CNA had forgotten to inform the nurse of such.

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