Articles Posted in Infection

White Oaks Rehabilitation and Nursing Center received 22 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 21, 2020. The Woodbury 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 measures to adequately treat and care for residents’ bedsores / pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to provide residents with necessary treatment and services to promote the healing of pressure ulcers, prevent infection of pressure ulcers, and prevent the development of new ulcers. A February 2017 citation found that White Oaks Rehabilitation and Nursing Center did not ensure such for one resident. The citation states specifically that the physician’s wound care treatment orders for a resident’s Stage IV sacral pressure ulcer “were not revised to address the depth of the wound.” In an interview, the wound care physician stated that the wound’s measurements change with the position of the resident, that the wound was stable, and that he did not expect it to close, so the goal of its treatment was to prevent infection. A plan of correction undertaken by the facility included the evaluation of the resident and clarification of the treatment.

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Beach Terrace Care 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 Long Beach 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 care for residents’ bedsores/pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing home facilities must ensure residents receive the necessary care and services to promote the healing of pressure ulcers and bedsores. A May 2019 citation found that Beach Terrace Care Center did not comply with this section. An inspector found specifically that the nursing home “did not perform a timely assessment when a resident’s skin condition changed.” The resident in question had an open blister on their left heel, however, the facility had no documented evidence that this blister was assessed until two days after it was identified. According to this citation, although a Skin Assessment Sheet was filled out to inform the facility’s Wound Care Nurse, no note was written in the resident’s chart at the time it was identified. The citation states that this deficiency had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the education of facility nursing staff on new procedures for documenting skin impairments.

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Villagecare Rehabilitation and Nursing Center received 12 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 four surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not implement adequate measures to prevent and care for pressure ulcers and bedsores. Section 483.25(c) of the Federal Code states that nursing homes must ensure residents receive a quality of care that prevents those admitted without pressure sores from developing such unless their condition renders it unavoidable; and that residents who have pressure sores receive necessary and proper care.

A November 2016 citation found that Villagecare Rehabilitation and Nursing Center neglected to ensure the provision of necessary treatment to a resident with a documented stage 2 pressure ulcer. The citation states specifically that in the resident’s Nursing Skin assessment for October 7, 2016 “The box to be checked indicating the presence of a pressure ulcer was not checked,” and the “skin examination section documented intact skin and the comment section was blank.” It goes on to state that there was an absence of documented evidence any “wound care orders were obtained when the pressure ulcer was identified” on October 6, 2016. In an interview, a Certified Care Associated stated that when she first cared for the resident, she informed a nurse that the resident had experienced skin breakdown; the Nurse Practitioner stated in an interview, however, that she documented the resident’s skin as dry and intact, and “may have missed identification of the sacral pressure ulcer.” A plan of correction undertaken by the facility included the in-servicing of nursing and medical staff.

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