Articles Posted in Infection

Rego Park Nursing Home received 22 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 deficiencies they describe include the following:

1. The nursing home did not ensure residents were free from abuse. Section 483.12 of the Federal Code stipulates that nursing home residents have a right to freedom from abuse and neglect. An August 2019 citation found that Rego Park Nursing Home failed to protect a resident from abuse. The citation specifically found that a Certified Nursing Assistant was captured on video camera footage kicking a resident twice in the facility’s dining room, “once on the left leg and once on the left leg.” The resident was subsequently seen bleeding and transported to the local hospital, where the resident received “11 sutures on the left leg and 10 sutures on the right leg.” Following the incident, the Assistant was terminated from the facility, and arrested by local police.

2. The nursing home did not take adequate steps to investigate allegations of abuse. Section 483.12 of the Federal Code requires nursing homes to respond to allegations of abuse, neglect, exploitation, or mistreatment by providing evidence that alleged violations are investigated and that the results of investigations are reported to relevant authorities. An August 2018 citation found that Rego Park Nursing Home did not provide for the thorough investigation of a resident’s injury. The citation states specifically that a resident was found “with yellow-green discoloration underneath the eyes and bridge of the nose.” An investigation of the injury, according to the citation, omitted statements or interviews from staff who had worked with the resident in the days preceding the injury. The citation states further that “The statements that were obtained did not include any information regarding the person’s interactions with the resident, and the investigation did not address that the injury was resolving at the time it was identified and reported.” The findings concluded that these deficiencies had the “potential to cause more than minimal harm.”

Midway Nursing Home received 34 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Maspeth nursing home’s citations resulted from a total of six inspections by state surveyors, and number two more than the statewide average of 32 citations. The violations they describe include the following:

1. The nursing home did not provide adequate supervision to prevent residents from experiencing accidents such as elopement. Section 483.25 of the Federal Code states that nursing home facilities must provide an environment as free as possible from accident hazards. A December 2016 citation found that Midway Nursing Home failed to comply with this citation by providing inadequate supervision to prevent a resident from eloping from the facility. The citation states specifically that the resident had been “identified at risk for elopement and had a wander guard in place.” However, according to the citation, the resident in question “walked out of the facility unknown to staff.” In an interview, the facility’s Director of Nursing stated that the resident’s monitoring “should have been increased.” In another interview, the facility’s administrator stated that a surveillance camera had not recorded any data, but he “was not aware that the camera was not reco[r]ding.” The citation notes that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not take adequate measures prevent and control the transmission of infection. Under Section 483.80 of the Federal Code, nursing homes must “establish and maintain an infection prevention and control program” that ensures residents a “safe, sanitary and comfortable environment.” An April 2017 citation found that the nursing home failed to comply with this section in two instances. In one, an inspector observed a Licensed Practical Nurse neglecting to clean a reusable blood glucose finger-stick meter between residents. In another, an inspector observed four separate facility nurses using “improper handwashing techniques” while providing care to residents, including during the administration of medication and wound care. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

Promenade Rehabilitation and Health Care Center received 34 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The facility was also the subject of a 2016 fine of $8,000 in connection to findings it violated health code provisions regarding social services, accidents, quality assessment and assurance, and administrative practices and procedures. The Rockaway Park nursing home’s citations resulted from a total of six inspections by state surveyors. The violations they describe include the following:

1. The nursing home did ensure residents received adequate supervision to prevent elopement. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide residents with a setting as free as possible from accident hazards, and with adequate supervision to prevent them from sustaining accidents such as elopement. A May 2018 citation found that Promenade Rehabilitation and Health Care failed to ensure one of its residents received adequate supervision to prevent the resident from leaving the facility. The citation specifically states that the resident had been identified as “at risk for elopement,” and eloped after being escorted to an appointment at the local hospital. According to the citation, a review of the hospital’s security camera recording revealed that the resident’s escort “was distracted and did not supervise [the resident] while they were both in the lobby area of the hospital,” at one point exiting the building for a period of ten minutes and leaving the resident alone. The facility’s plan of correction in response to the citation included the termination of the escort in question.

2.  The nursing home did not keep resident drug regimens free from unnecessary drugs. Section 483.45 of the Federal Code requires nursing homes to maintain “each resident’s drug regimen… free from unnecessary drugs.” An April 2017 citation describes the nursing home’s failure to ensure that residents using medication for an unspecified condition “receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.” The citation states specifically that the facility did not implement one resident’s pharmacist-recommended and physician-approved dose reduction for klonopin. The citation states that this deficiency had the “potential to cause more than minimal harm.”

Peninsula Nursing and Rehabilitation Center received 47 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Far Rockaway nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not take adequate measures to minimize the risk of accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents an environment as free as possible from accident hazards, with adequate supervision to prevent accidents. A July 2017 citation found that the nursing home did not provide one resident with an assistive device necessary to mitigate the risk of accidents. The citation states specifically that the resident, who had been identified as “at risk for elopement,” was provided with a wander guard device to alert facility staff if the resident attempted to leave the facility. According to the citation, staff removed this device while the resident was being transferred to the local hospital, but did not put it back on the resident upon return. “The resident then left the facility undetected,” the citation states. According to the citation, this failure resulted in the “potential to cause more than minimal harm.”

2. The nursing home did not adequately implement infection control measures. Section 483.65 of the Federal Code requires nursing homes to design and maintain an infection control program that provides residents with “a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.” An April 2016 citation found that the nursing home did not ensure its infection control members were properly maintained so as to prevent the transmission of disease and infection. The infection states specifically that there was no documented evidence indicating that a resident had received a Purified Protein Derivative skin test since they were admitted to the facility, in contravention of facility policy. The facility’s immunization policies and procedures were reviewed and revised in response to this citation.

New Glen Oaks Nursing Home received 34 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Glen Oaks nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not ensure the potential for accidents was adequately minimized. Under Section 483.25 of the Federal Code, nursing homes must provide residents with adequate supervision to prevent accidents, and further ensure an environment as free as possible from accident hazards. An August 2017 citation found that New Glen Oaks Nursing Home did not provide an adequately accident-free environment, with an inspector specifically observing “an uncapped soiled razor… in an open box on top of [a] resident’s bedside table.” In an interview, the facility’s nursing supervisor stated that the facility’s Certified Nursing Assistants were “aware that razors are not to be left at residents’ bedside and should be disposed of,” and the facility’s Director of Nursing Services stated that the razor in question “should not be kept at the resident’s bedside.”

2. The nursing home did not take adequate measures to prevent the potential spread of 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 and to help prevent the development and transmission of communicable diseases and infections.” A July 2018 citation found that New Glen Oaks Nursing Home failed to comply with this section. The citation specifically states that facility staff were observed assisting residents during mealtime “without washing or sanitizing their hands in the dining room.” For instance, a Certified Nursing Assistant was observed putting used and dirty trays on a rack, then cutting up a resident’s food, then pouring water into a cup and giving it to the resident, all without washing or sanitizing her hands. The citation describes this deficiency as “widespread” and as having the “potential to cause more than minimal harm.”

Queen of Peace Residence received 12 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Queens Village 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 protect residents from neglect. Section 483.12 of the Federal Code ensures nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A March 2018 citation found that Queen of Peace Residence failed to protect residents from neglect. An inspector specifically found that a resident was “left unattended for 1 1/2 hours on a commode which was located in the resident’s room in an area where the resident’s call bell was not within reach.” A Certified Nursing Assistant stated that on the morning in question, her responsibility was to “cover the floor,” ensure “all residents go to Mass in the Chapel,” and then stay in the facility’s TV room with residents not attending mass; the resident in question was suffering from a cold and staying in her room, according to the CNA, who said “her mistake was that she did not knock on the door to… see if she was in her room.” Another CNA—who had covered for the first CNA while she was on break—had not informed her “that she put the resident on her commode,” according to the citation, which noted that disciplinary actions were administered to the CNAs involved and that CNAs and nursing staff were subsequently educated.

2. The nursing home did not adequately implement its infection control practices. Section 483.80 of the Federal Code requires nursing homes to create 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 March 2018 citation found that Queen of Peace Residence did not ensure staff followed its infection control practices. An inspector specifically found that a Registered Nurse “used a contaminated glove to smear ointment on a resident’s wound” during one resident’s pressure ulcer care. In an interview, the RN acknowledged that she used the incorrect technique, stating that “it was wrong to apply the ointment on the resident’s buttocks after contamination of the glove” and that she had to improve her treatment technique.

Queens Nassau Rehabilitation and Nursing Center received 11 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The facility has also received two fines: one $10,000 fine in April 2018 over findings of multiple health code violations; and one $20,000 fine in November 2011 over findings it violated health code provisions regarding quality of care and physician visits. The Far Rockaway 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 proper follow infection prevention and control policies and procedures. Under Section 483.80 of the Federal Code, nursing home facilities must design and execute “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment” for residents. An August 2018 citation found that Queens Nassau Rehabilitation and Nursing Center did not ensure staff performed “proper hand hygiene between residents to prevent the spread of infections.” An inspector specifically observed a Licensed Practical Nurse administering medications without performing hand hygiene. An inspector also observed the Licensed Practical Nurse in question assisting a resident with care and opening medication for another resident without performing hand hygiene in between. The citation states that this “deficient practice was observed on multiple occasions.”

2. The nursing home did not ensure the provision of services by qualified persons in accordance with residents’ plans of care. Section 483.21 of the Federal Code requires that “services provided or arranged” by nursing home facilities and outlined in residents’ comprehensive care plans must be “provided by qualified persons in accordance with each resident’s written plan of care.” An April 2017 citation found that the nursing home did not ensure one resident received services in accordance with their plan of care. The citation specifically states that while the resident had been ordered by a physician to wear a right hand mitten, the resident was observed not wearing such. The mitten was intended to prevent the resident from pulling out their feeding tube, according to the citation, which notes that a Certified Nursing Assistant said in an interview that she “was under the assumption that as long as the resident is calm the mitten does not have to be on.”

Buena Vida Continuing Care & Rehab Center received 23 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The Brooklyn 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 measures to prevent accidents. Section 483.25 of the Federal Code requires nursing home facilities to remain “as free of accident hazards as is possible” and to provide residents with adequate supervision and assistance to prevent accidents. An August 2019 citation found that Buena Vida Continuing Care & Rehab did not ensure one of its residents was free of accident and injury. The citation specifically found that the resident was served a dinner tray that included two cups of hot water. The resident was attempting to prepare tea when one of the cups spilled hot water onto her thighs, causing her to sustain an injury. The citation states that there was no documented instructions for facility staff regarding safe water temperatures when reheating water in the microwave, and that the incident resulted in “actual harm” to the resident.

2. The nursing home failed to ensure residents’ drug regimens were free from unnecessary medications. Section 483.45 of the Federal Code requires nursing homes to keep “each resident’s drug regimen… free from unnecessary drugs.” A May 2019 citation found that Buena Vida Continuing Care & Rehab used Valporic acid to treat a resident’s anxiety disorder and another unspecified condition “without ordering labs to monitor the Valporic acid levels” in the resident. The citation states that there was no evidence lab work was performed to test and monitor the acid levels, and notes that the facility’s Medical Director stated in an interview that “labs should have been done on the Valporic acid levels at least every 6 months even as a baseline.”

New Carlton Rehab and Nursing Center received 45 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 2011 fine of $10,000 in connection to findings it violated health code provisions regarding pressure sores. The Brooklyn 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 adequately implement infection control policies and procedures. Under Section 483.80 of the Federal Code, nursing homes must establish an infection prevention and control program that provides residents with a safe and sanitary environment. A November 2019 citation found that New Carlton Rehab and Nursing Center failed to comply with this section in two capacities. The citation states specifically that an inspector observed oxygen tubing making contact with the facility’s floor “on several occasions”; and that the facility did not annually review its policies and procedures concerning infection control. A plan of correction undertaken by the facility included the education of nursing staff on infection control practices including those pertaining to oxygen tubing, and the implementation of randomized audits of residents who receive supplemental oxygen.

2. The nursing home did not adequately ensure the implementation of food safety standards. Under Section 483.60 of the Federal Code, nursing homes are required to ensure the storage, preparation, distribution, and service of food in accordance with professional safety standards. A November 2019 citation found that New Carlton Rehabilitation and Nursing did not take adequate measures to prevent food-borne illness. An inspector specifically observed unlabeled and undated food items in a “cook prep fridge and meat freezer”; a cook prep fridge that contained employees’ lunch food items; food items in a freezer that exhibited freezer burn and were “falling out of packaging”; and food boxes that were “crushed, opened, and water marked” in the facility’s freezer. The citation states that this deficiency had the “potential to cause more than minimal harm.”

Seagate Rehabilitation and Nursing Center received 27 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 22, 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 keep its residents free from the unnecessary use of physical restraints. Section 483.10 of the Federal Code ensures nursing home residents the right “to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.” A November 2019 citation found that Seagate Rehabilitation and Nursing Center did not ensure that in a case where a resident was indicated for the use of restraints, facility staff implemented “used the least restrictive alternative for the least amount of time and documented ongoing re-evaluation of the need for restraints.” An inspector found specifically that there was a lack of documented evidence of an ongoing need by the resident for the use of an abdominal binder, that the resident was reevaluated for its use, and that behavior necessitating the use of the binder were documented by the facility. A plan of correction undertaken by the facility included an assessment of the resident’s need for the restraint, which found that she no longer needed it, and as such it was removed.

2. The nursing home did not adequately ensure the implementation of infection prevention and control practices. Per Section 483.80 of the Federal Code, nursing home facilities must “establish and maintain an infection prevention and control program.” A February 2018 citation found that Seagate Rehabilitation and Nursing Center did not maintain infection control practices in two instances. In one, an inspector observed a resident receiving oxygen through nasal cannula with part of the device’s tubing resting on the floor of their room. The inspector also observed a Licensed Practical Nurse pick up the tubing and put it on the resident’s bed’s side rail, rather than discarding it and replacing it with new tubing. In another instance, an inspector observed a Registered Nurse providing wound care to a resident without employing effective hand hygiene or other infection control practices, specifically neglecting to clean clean a table or wash her hands between removing her gloves and opening gauze. A plan of correction undertaken by the facility included the in-servicing of the staff members in question.

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