Articles Posted in Neglect

Smithtown Center for Rehabilitation & Nursing Care received 11 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 10, 2020. The Smithtown 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 accident prevention measures. Section 483.25 of the Federal Code states that nursing homes must provide residents with “adequate supervision and assistance devices to prevent accidents.” An August 2019 citation found that Smithtown Center for Rehabilitation & Nursing Care did not ensure such for one resident. The citation states specifically that an inspector observed the resident’s medications “observed left on the bedside table and… signed as administered by the Medication Licensed Practical Nurse.” According to the citation, the resident’s care plan contained no plan for self-administering of medications, and the LPN stated in an interview that she had left the room because she was called to assist another resident, although “she knows that she is not supposed to leave medications with the residents.”

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Healthcare workers at Fairview Rehab & Nursing Home recently described what they called “crazy” conditions at the Queens facility, according to an April 20, 2020 report by Gothamist. One of the staff members said she showed up for a job interview and was “whisked” through a training session and hired immediately, with the nurse leading the training session explaining that many of the facility’s staff and managers were “out sick with COVID-19.” This nurse explained that the facility had a nurse-to-resident ratio of 40:1, and then asked the prospective job applicants who “could begin a double shift immediately.”

Conditions inside the nursing home are so severe, according to the report, that most of the facility’s 200 residents have “acute pressure ulcers,” meaning it has been days since they were turned over by nurses. “They’re slumped over in bed, just laying there rotting,” one nurse told Gothamist. The report also describes shortages of infection control supplies like gloves, hand sanitizers, and even medication. Staff were reportedly instructed not to record missing medication as out of stock, but instead to “note that a resident refused it.” Inexperienced staff are in some instances “given high-level tasks,” workers said, including one instance when a nursing assistant inserted a resident’s nasal cannula “upside down,” a “potentially deadly error” that resulted in a “gasping fit” before it was caught.

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Waters Edge Rehab & Nursing Center at Port Jefferson received 21 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 24, 2020. The facility has also received three fines: a 2019 fine of $2,000 in connection to findings in a 2018 inspection that it violated unspecified health code provisions; a 2016 fine of $10,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding accidents and supervision; and a 2016 fine of $4,000 in connection to findings in a 2012 inspection that it violated health code provisions regarding accidents and administration. The Port Jefferson 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 supervise residents. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with adequate supervision to prevent accidents. An October 2018 citation found that Waters Edge Rehab & Nursing Center at Port Jefferson did not ensure such for one resident. The citation states specifically that the resident “was left unsupervised on an outside patio in direct sunlight with external temperature at 85 degrees Fahrenheit for at least an hour and 15 minutes.” As a result, according to the citation, the resident suffered heat exhaustion and dehydration, and needed to be administered intravenous fluid. The citation states that this incident resulted in “actual harm” to the resident.

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Westhampton Care Center received 18 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 24, 2020. The facility has also received a 2019 fine of $10,000 in connection to findings in a 2018 inspection that it violated unspecified health code provisions. The Westhampton 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 protect residents from neglect. Section 483.12 of the Federal Code ensures provides nursing home residents the right to freedom from abuse and neglect. A September 2018 citation found that Westhampton Care Center did not ensure such for one resident. The citation states specifically that the resident required the use of a mechanical lift device for transfers between surfaces. However, on one instance, two Certified Nursing Assistants transferred the residents without the use of the lift, and the resident subsequently “fell to her knees.” The CNAs did not report the incident to authorities, according to the citation, nor the resident’s “complaint of pain.” Afterward, the resident was transferred to a local hospital. A plan of correction undertaken by the facility included the suspension pending investigation of both CNAs.

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Yonkers Gardens Center for Nursing 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 April 24, 2020. The Yonkers 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 prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments that are as free as possible from accident hazards, and that they provide every resident with adequate supervision and assistance to prevent accidents. A May 2019 citation found that Yonkers Gardens Center for Nursing and Rehabilitation did not ensure such. The citation specifically describes a resident who was cognitively impaired and depended on the help of one staffer for toileting, hygiene, and dressing. It goes on to describe an interview in which the resident said that due to a broken commode frame in his bathroom, he had been using a public restroom in the hall near his room, and “had fallen several times in his room and once in the lavatory.” A plan of correction undertaken by the facility included the placement of the left side of the commode frame in the resident’s bathroom, and the evaluation of the resident by a physical therapist.

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The Osborn received 16 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 24, 2020. The facility has also received a 2016 fine of $10,000 in connection to findings in a 2014 inspection that it violated health code provisions regarding facility administration and resident rights. The Rye 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 employ adequate measures to prevent infection. Section 483.80 of the Federal Code states that nursing home facilities must create and uphold an infection prevention and control program designed with an aim “to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A November 2019 citation found that The Osborn did not adequately ensure staff followed proper hand hygiene and gloving technique so as to mitigate the risk of cross-contamination and the spread of infectious pathogens. The citation states specifically that an inspector involved a pressure ulcer wound care procedure in which a registered nurse did not wash her hands after discarding a soiled wound dressing and pair of gloves, and before donning a new pair of gloves. The nurse was then observed pouring sterile water on cleanser until gauze sponges and cleaning the resident’s wound without having sanitized her hands. In an interview after the procedure, the nurse “confirmed that she did not practice appropriate hand hygiene.”

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Huntington Hills Center for Health and Rehabilitation received 26 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 3, 2020. The facility has also received three fines: a 2019 fine of $10,000 in connection to findings in a 2019 inspection that it violated unspecified health code provisions; a 2019 fine of $10,000 in connection to findings in a 2018 inspection that it violated unspecified health code provisions; and a 2016 fine of $12,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding accident supervision and dietary services. The Melville 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 ensure residents were protected from neglect involving a fall. Section 483.12 of the Federal Code provides nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A February 2019 citation found that Huntington Hills Center for Health and Rehabilitation did not ensure such for one resident. The citation states specifically that the resident was transferred by a Certified Nursing Assistant and a Licensed Practical Nurse from the floor to their bed without those individuals “reporting to, or ensuring that the resident was assessed by, a Registered Nurse (RN), Nurse Practitioner (NP) or a physician (MD) after an unwitnessed fall.” The citation states further that after the fall, the resident in question experienced pain and was not able to bear weight to their right leg. No physician or NP was notified, according to the citation, until seven hours after facility staff noted a change in the resident’s condition, and the resident did not receive an assessment by a clinician “for at least 23 hours after the fall,” after which they were transferred to the hospital where a fracture was discovered. The citation states that these deficiencies resulted in “actual harm” to the resident.

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Medford Multicare Center for Living received 63 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 4, 2020. The Medford nursing home’s citations resulted from a total of 19 surveys by state inspectors. 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 requires nursing homes to ensure each resident’s “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A May 2018 citation found that Medford Multicare Center for Living did not ensure such for one resident. The citation states specifically that a Certified Nursing Assistant gave the resident food “that was intended for another resident,” and that the resident subsequently consumed the food from their tray and choked. A plan of correction undertaken by the facility included the termination of the CNA and the revision of the resident’s care instructions to include a “nothing by mouth” instruction.

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Carillon Nursing and Rehabilitation Center received 21 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 28, 2020. The Huntington 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 implement adequate measures to prevent abuse. Section 483.12 of the Federal Code ensures nursing home residents “the right to be free from abuse.” An August 2019 citation found that Carillon Nursing and Rehabilitation Center did not ensure this right for one resident. The citation states specifically that a Certified Nursing Aide pushed a resident “in her bed using his hand over her head/face three times when the resident was trying to get out of bed.” The citation states that according to the patient, the CNA in question “was verbally abusive,” put his hand over her face, and pushed her head into her pillow “three times asking her to shut up.” The resident stated further that the CNA’s aggression and demeanor “shocked” her. A plan of correction undertaken by the facility included the termination of the CNA in question.

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Good Samaritan Nursing and Rehabilitation Care Center received 21 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 28, 2020. The Sayville 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 provide adequate pressure ulcer (bedsore) care. Section 483.25 of the Federal Code requires nursing homes to ensure that a resident with pressure ulcers receives “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” A March 2018 citation found that Good Samaritan Nursing and Rehabilitation Care Center did not ensure such for one resident. The citation states specificaly that the resident developed a deep tissue injury on their right heel while in the facility, but that “multiple observations were made of the heel not being offloaded (to prevent contact with any surface) per physician’s orders.” In an interview, the facility’s Director of Nursing Services stated that the facility should have provided the resident with “better coordinated” care and that the resident’s “care plan should have been updated” with more specific interventions.

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