Articles Posted in Infection

Seneca Nursing & Rehabilitation Center has received 17 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 28, 2020. The Waterloo 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 supervise residents. Under Section 483.25 of the Federal Code, nursing homes must provide residents with adequate supervision to prevent accidents. A May 2018 citation found that Seneca Nursing & Rehabilitation Center did not ensure such. The citation states specifically that a resident managed to elope from the nursing home undetected. The resident in question had been assessed “at high risk for wandering,” according to the citation, and exited the facility through the front door with a visitor who did not know the resident. A Registered Nurse later checked the door and found “it did not latch tight and was easily opened.” According to the facility’s Maintenance Supervisor, “when this event happened, the door must have been opened only 10 inches or so, and the door closer did not have enough power to pull the door fully shut so that the magnet would engage.” A plan of correction undertaken by the facility included the testing of doors for proper closure and alarming.

2. An October 2017 citation also found Seneca Nursing & Rehabilitation Center fell short of its duty to prevent accidents. It specifically concerns “suction machines that were not readily assembled and ready for use on units with residents at risk for aspiration.” It goes on to state that according to a Registered Nurse, “there were many residents who were aspiration risks.” A plan of correction undertaken by the facility included a monthly audit of the suction machines.

Huntington Living Center has received 38 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 28, 2020. The Waterloo 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 take adequate measures to prevent accidents. Under Section 483.25 of the Federal Code, nursing homes must create a resident environment as free as possible from accident hazards, and with adequate supervision to prevent accidents. A February 2020 citation found that Huntington Living Center did not ensure such. The citation states specifically that a resident smoked in an area that was not designated for smoking, and the resident was further storing their own lighter. The citation goes on to state that the resident’s smoking supplies were supposed to be stored in the nurse’s unit, and that the resident was supposed to smoke off-property at the far side of a parking lot. In an interview, the resident stated that “they were supposed to smoke over on the next street by the church, but it was further away,” and that “they try to remember to lock the lighters up but they do not always remember to do that.” A plan of correction undertaken by the facility included a review of the facility’s smoking policies and protocols.

2. The nursing home did not adequately prevent infection. Under Section 483.80 of the Federal Code, nursing home facilities are supposed to endeavor to prevent and control infections via an infection control program. A February 2020 citation found that Huntington Living Center did not ensure such. The citation states specifically that the nursing home’s employees “did not follow appropriate infection control techniques or hand hygiene” for three residents reviewed for blood glucose testing and wound infections. It goes on to state that a blood sugar monitoring device was not properly cleaned after three resident uses, and that appropriate hand hygiene was not followed for another resident. A plan of correction undertaken by the facility included the re-education of relevant staff.

Ellis Residential & Rehabilitation Center has received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 28, 2020. The facility has also received a 2016 fine of $20,000 in connection to findings in an earlier inspection that it violated health code provisions regarding accidents, resident assessments, abuse, staff treatment of residents, and administrative practices. The Schenectady 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 employ adequate infection-control measures. 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 January 2019 citation found that Ellis Residential & Rehabilitation Center did not ensure such. The citation states specifically that it failed to ensure staff who did not get a flu shot properly wore surgical masks in resident areas, “leaving residents at higher risk for transmission of the flu.” It also states that with respect to a resident on contact precautions, the nursing home “did not ensure that staff donned a gown and gloves prior to entering the resident’s room.” The citation finally states that the nursing home failed to ensure the annual review of its Infection Control policies. A plan of correction undertaken by the facility included the audit of staff required to wear masks, and the re-education of staff regarding face masks.

2. The nursing home took inadequate care of residents’ pressure ulcers. Section 483.35 of the Federal Code states that nursing homes must provide pressure ulcer patients with necessary care to promote healing. A January 2019 citation found that Ellis Residential & Rehabilitation Center failed to ensure such for one resident, and for a second resident “did not initiate interventions to address identified pressure ulcer risk factors to prevent pressure ulcer development with the subsequent development of a pressure ulcer.” The citation goes on to state that the first resident’s records did not contain any documentation reflection the provision of care to the resident’s pressure ulcers. The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the education of registered nursing staff.

Glendale Home has received 23 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 28, 2020. The Scotia 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 failed to adequately prevent infection. Under Section 483.80 of the Federal Code, nursing home facilities must endeavor to prevent and control infection via the establishment and maintenance of a program to provide residents with a sanitary and comfortable environment. A March 2019 citation found that Glendale Home failed to ensure such. The citation states specifically that the nursing home “did not ensure standard precautions were maintained during a dressing change” and that it further failed to maintain standard precautions while a staffer administered a resident’s eyedrops. The citation goes on to state that “a face mask was not properly worn by an employee while on a resident unit.” A plan of correction undertaken by the facility included the assessment of the first resident’s wounds, the assessment of the second resident’s eyes, and the re-education of nursing staff on relevant policies and procedures.

2. Glendale Home received another citation for deficiencies in its infection control practices in June 2017. According to this citation, the nursing home did not maintain proper precautions during dressing changes for two residents. In one instance, staffers were observed leaving equipment on the floor without protective covering, and failing to change gloves after contaminating them. In another, a nurse did not wash her hands or change her gloves during two changes of a resident’s inner knee dressing, and “did not treat the wounds as two separate wounds as she did not complete one dressing change to the inner knee, wash her hands and change gloves and then proceed to the next inner knee dressing change.” The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the in-servicing of relevant staff.

Steuben Center for Rehabilitation and Healthcare has received 38 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received a 2018 fine of $10,000 in connection to findings in a 2017 inspection that it violated unspecified health code provisions. The Bath 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 protect residents from abuse. Section 483.12 of the Federal Code grants nursing home residents “the right to be free from abuse.” A January 2018 citation found that Steuben Center for Rehabilitation and Healthcare did not ensure such for one resident. The citation states specifically that a Licensed Practical Nurse was witnessed undressing and washing the resident after the resident told the LPN to stop, then pushing the resident onto the toilet when the resident attempted to stand up. The citation also states that the LPN told another nurse at the facility “that she wanted to use the biggest needle she could find on the resident.” A plan of correction undertaken by the facility included the suspension and subsequent termination of the LPN.

2. The nursing home did not properly prevent infection. Section 483.80 of the Federal Code stipulates that nursing homes must maintain a program to prevent and control infection. A July 2018 citation found that Steuben Center for Rehabilitation and Healthcare did not ensure such for two residents. The citation states specifically that a nurse “did not properly disinfect the blood glucose testing machine (glucometer) before or after resident use.” In an interview, the nurse said “she should have wiped the glucometer down between residents” and that “she usually cleans the glucometer with bleach wipes that are located at the nurses’ station.” The facility’s Assistant Director of Nursing said in another interview that “she would expect the nurse to clean the glucometer in between residents using the approved bleach wipes.”

Oak Hill Rehabilitation and Nursing Care Center has received 22 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The Ithaca 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 prevent significant medication errors. Under Section 483.25 of the Federal Code, nursing homes must ensure residents “are free of any significant medication errors.” A February 2020 citation found that Oak Hill Rehabilitation and Nursing Care Center did not ensure such for three medications. The citation states specifically that the residents “did not receive significant medications as ordered.” A plan of correction undertaken by the facility included the administration to two residents of their missed doses, and an RN Assessment of all three residents, one of whom was already discharged.

2. The nursing home did not properly prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to create and maintain a program designed to ensure residents a safe and sanitary environment via the maintenance and control of infection. A February 2019 citation found that Oak Hill Rehabilitation and Nursing Care Center did not ensure such for one resident. The citation states specifically that the resident’s catheter bag and tubing were resting directly on the facility’s floor, in violation of health policy. It goes on to state that the facility’s washers and dryers “were not maintained according to user manual,” and that “There was no documented facility policy for the maintenance of the washers and dryers.” A plan of correction undertaken by the facility included the placement of the resident’s catheter in a labeled basin, and the required maintenance of the washers and dryers.

Groton Community Health Care Center Residential Care Facility has received 96 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received fines totaling $20,000 in connection to findings that it violated health code provisions regarding equipment conditions, pressure sore care, accidents, and administrative practices. The Groton 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 adequately comply with infection control practices and procedures. 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 January 2019 citation found that Groton Community Health Care Center Residential Care Facility did not ensure such. The citation states specifically that facility staff did not perform hand hygiene while changing a resident’s wound pressure ulcer wound dressing. The citation goes on to describe a Licensed Practical Nurse who, while treating the resident’s wound, “removed her soiled gloves after removing the old dressing, then immediately donned another pair of gloves without performing hand hygiene.” In an interview, the nurse said “she should have performed hand hygiene between glove changes.” In another interview, the facility’s infection control nurse said that “she expected staff to perform hand hygiene after removing and before replacing gloves when completing a dressing change.”

2. The nursing home did not adequately prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes must keep residents “free of any significant medication errors.” A May 2018 citation found that Groton Community Health Care Center Residential Care Facility failed to ensure such for one resident. It goes on to describe specifically a resident who “was not consistently provided with her heart medication as ordered and the facility did not identify the root cause to prevent reoccurrence.” A plan of correction undertaken by the facility included the review and revision of the facility’s medication error policy and the provision of a monthly review of medication error’s to the facility’s QAA committee and Medical Director.

Cayuga Nursing and Rehabilitation Center has received 96 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received fines totaling $36,000 in connection to findings that it violated health code provisions concerning resident rights, accidents, quality of care, pressure ulcers, food standards, administrative practices, and more. The Ithaca 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 employ adequate infection-control procedures. Section 483.80 of the Federal Code stipulates that nursing homes must create and maintain an infection control program so as to stave off the development and transmission of disease. A June 2019 citation found that Cayuga Nursing and Rehabilitation Center did not ensure such. The citation describes the facility’s staff’s failure to “follow proper infection control technique during a skin treatment observation,” specifically describing failures to wipe down equipment, perform hand hygiene, and use proper equipment. The equipment goes on to state that the facility did not employ proper infection control technique while administering medication to seven residents, specifically describing a nurse who did not perform hand hygiene between each resident’s medication administration. A plan of correction undertaken by the facility included the re-education of the nurse in question.

2. The nursing home did not employ adequate measures to care for pressure ulcers. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with necessary treatment and services to prevent and/or heal pressure ulcers. A December 2017 citation found that Cayuga Nursing and Rehabilitation Center did not ensure such for one resident. The citation specifically describes a resident who was identified on admission as having a Stage II pressure ulcer, but “was not re-assessed timely and she was not provided with pressure relief interventions as planned to promote healing.” A plan of correction undertaken by the facility included the education of relevant staff and the revision of the resident’s plan of care.

Beechtree Center for Rehabilitation and Nursing has received 65 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received a 2016 fine of $10,000 in connection to findings in a 2012 inspection that it violated health code provisions concerning abuse, accidents, staff treatment of residents, and administrative practices. The Ithaca nursing home’s citations resulted from a total of nine surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not employ adequate measures to prevent infection. Section 483.80 of the Federal Code requires nursing homes to mitigate the risk of infection via the creation and maintenance of an infection control program. An August 2019 citation found that Beechtree Center for Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the facility did not maintain infection control standards during a resident’s pressure ulcer dressing change. It goes on to describe the facility’s failure to “provide appropriate personal protective equipment (PPE) or a way to perform hand hygiene in the soiled laundry sorting area; and washers and dryers were not maintained according to the user manual.” The citation describes these deficiencies as having the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the re-dressing of the resident’s pressure ulcer and the placement of PPE in the laundry room.

2. The nursing home did not adequately supervise residents. Section 483.25 of the Federal Code requires nursing homes to provide residents with adequate supervision to prevent accidents. An August 2019 citation found that Beechtree Center for Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the facility had no plan in place to address the resident’s smoking. it goes on to state that the resident in question “was observed smoking independently after he had been assessed by the facility to be a safety risk and not eligible for safe-smoking.” The resident, who is described as having “impaired tactile sensation, did not light his own cigarette safely and was likely to drop smoking material.” According to the citation, he flicked ashes onto the ground and threw cigarette butts on the ground but “was not able to put them out.” An assessment found that the resident “was a safety risk and was not eligible for a safe-smoking contract.” A plan of correction undertaken by the facility included the facility’s provision, to the resident, of a smoking alternative.

Washington Center for Rehabilitation and Healthcare has received 49 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 facility has also received a total of $74,000 in fines in connection to findings that it violated health code provisions concerning infection control, accidents, medication errors, resident behavior, hydration, administration, and more. The Warsaw 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 protect residents from physical abuse. Section 483.12 of the Federal Code grants nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A January 2020 citation found that Washington Center for Rehabilitation and Healthcare failed to ensure this right for two residents. The citation specifically states that it did not ensure the two residents “were free from physical abuse related to a resident to resident altercation.” It describes an incident in which one resident attempted to pull another resident’s wheelchair “and was swinging a fist at the resident,” who in response “used his reacher and struck” the resident “twice in the face,: at which point a staffer separated the residents. A plan of correction undertaken by the facility included a rooming change for the residents, who were roommates.

2. A November 2019 citation also found that Washington Center for Rehabilitation and Healthcare did not protect residents from abuse. The citation specifically describes a Registered Nurse Supervisor assaulting a resident. According to the citation, the RNS instructed two other staffers to to hold the resident’s hands while the RNS placed medication crushed into pudding into the resident’s mouth. Per a written statement, one of those staffers said “that RNS #1 had instructed LPN #1 and CNA #1 to hold Resident #1’s hands, then put medication into his/her mouth. When RNS #1 put the medication in Resident #1’s mouth, she tipped his/her head back and put her hand in front of his/her mouth.” A plan of correction undertaken by the facility included the suspension, investigation, and termination of the RNS.

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