Articles Posted in Nursing Home Violations

A new report by the Associated Press illustrates the devastating toll of the Covid-19 pandemic on nursing home residents across the country. The tragedy is not limited to Covid-19 deaths themselves, but also to deaths from other causes that ballooned as staff dealt with Covid-19 patients. One expert cited in the report estimated that “for every two COVID-19 victims in long-term care, there is another who died prematurely of other causes.” Ultimately, they concluded, there may have been more than 40,000 more “excess deaths” in nursing homes since March, compared to the same period in previous years.

The expert, professor Stephen Kaye at the University of California, San Francisco, attributes the spike in excess deaths to staffing issues at nursing homes. By comparing death rates at nursing homes that experienced outbreaks to nursing homes that didn’t, he found that “the more the virus spread through a home, the greater the number of deaths recorded for other reasons,” which suggests that healthcare workers were “consumed” caring for Covid-19 patients—and/or contracted the illness themselves—and therefore unable to devote adequate care to residents without Covid-19. Kaye suggests this effect was compounded by longstanding staffing issues at nursing homes: “In 20 states where virus cases are now surging,” the report observes, “federal data shows nearly 1 in 4 nursing homes report staff shortages.” Continue reading

Baptist Health Nursing and Rehabilitation Center has received 34 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 two fines totaling $12,000 in connection to findings that it violated health code provisions, among others, regarding quality of care.. The Scotia 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 properly implement infection-control measures. Under Section 483.80 of the Federal Code, nursing homes are required to take steps to prevent and control infection via the maintenance of an infection control program that ensures residents a comfortable and sanitary environment. An August 2017 citation found that Baptist Health Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that staff did not properly wear personal protective equipment when necessary, glucometers were not disinfected after use, and employees “did not observe Contact Precautions during Foley catheter care and when providing housekeeping services to 2 residents.” A plan of correction undertaken by the facility included the education of nurses on glucometer cleaning, the education of a certified nursing assistant on proper foley catheter emptying, the education of a housekeeper and CNA on contact precautions, and the education of nursing staff on wound care techniques.

Continue reading

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.

Kendal at Ithaca has received 16 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 three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent accidents. Under Section 483.25 of the Federal Code, nursing homes must ensure resident environments are “as free of accident hazards as is possible.” A July 2016 citation found that Kendal at Ithaca did not ensure such. The citation states specifically that the facility’s hot water was too hot. It goes on to describe “the hot water temperature [that] was determined to be over 120 degrees Fahrenheit.” It states further that a Hot Water Return Status form “did not document any action taken after the hot water that was found to be too hot,” and “no documented evidence elsewhere that any action was taken to reduce the hot water temperature after it was determined to be too hot.” A plan of correction undertaken by the facility included adjustments to the mixing valves in the affected units.

2. The nursing home did not adequately comply with food safety standards. Under Section 483.35 of the Federal Code, nursing homes must store and prepare food under sanitary conditions. A July 2016 citation found that Kendal at Ithaca did not ensure such in two of its four kitchens. The citation states specifically that “spoiled and outdated foods were stored in the cafeteria walk-in refrigerator” and that an employee tested the sink’s sanitizer concentration using “an unapproved method.” 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 discarding of spoiled and outdating food and the re-education of the employee in question.

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.

Contact Information