Articles Posted in Nursing Home Violations

Townhouse Center for Rehabilitation & Nursing received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 20, 2020. The facility has also received four fines: a 2019 fine of $10,000 in connection to findings in a 2019 inspection that it violated unspecified health code provisions; a 2018 fine of $16,000 in connection to findings in a 2018 inspection that it violated unspecified health code provisions; a 2017 fine of $2,000 in connection to findings in a 2017 inspection that it violated health code provisions regarding the use of physical restraints; and a 2017 fine of $4,000 in connection to findings in a 2016 inspection that it violated health code provisions regarding quality of care and administrative practices. The Uniondale nursing home’s citations resulted from a total of ten surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not ensure residents were protected from neglect. Section 483.12 of the Federal Code guarantees nursing home residents the right to “be free from… neglect.” An August 2018 citation found that Townhouse Center for Rehabilitation & Nursing did not ensure such for one resident. The citation describes specifically an instance in which the facility’s security guard on duty “left his post unattended,” after which a resident eloped. The resident was later found a block away from the nursing home and returned to it ‘without any injury.” A plan of correction undertaken by the facility included the termination of the security guard in question.

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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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The Grand Pavilion for Rehab & Nursing at South Point received 32 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 20, 2020. The facility has also received two fines: one 2016 fine of $8,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding resident rights and administration; and one 2011 fine of $10,000 in connection to findings in a 2010 inspection that it violated health code provisions regarding pressure sores. The Island Park 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 adequately protect residents from nursing home abuse. Under Section 483.12 of the Federal Code, nursing homes have a right to “be free from abuse, neglect, misappropriation of resident property, and exploitation.” A March 2019 citation found that The Grand Pavilion for Rehab & Nursing at South Point did not ensure one resident’s right to freedom from sexual abuse. The citation states specifically that a “cognitively intact resident… inappropriately touched another resident… who was assessed as having impaired cognition.” A plan of correction undertaken by the facility included the placement of the first resident on one-to-one observation until he could be “discharged to another appropriate facility.”

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Acadia Center for Nursing and Rehabilitation received 16 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 facility also received a 2015 fine of $4,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding resident medication errors. The Riverhead, NY 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 ensure residents were protected from abuse. Section 483.12 of the Federal Code stipulates that nursing home residents have “the right to be free from abuse.” An October 2019 citation found that Acadia Center for Nursing and Rehabilitation did not ensure one resident was free from abuse. The citation states specifically that a Certified Nursing Assistant witnessed a Licensed Practical Nurse “using foul language and hitting a legally blind resident with cognitive impairment twice on his forehead.” The citation states further that video surveillance documented this incident, and that the LPN was “immediately removed from her assignment.” A plan of correction undertaken by the facility included the termination of the LPN. Continue reading

Apex Rehabilitation & Care Center received 29 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 Huntington Station 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 abuse. Section 483.12 of the Federal Code requires nursing homes to ensure residents’ right to freedom from abuse. A December 2019 citation found that Apex Rehabilitation & Care Center did not ensure such for two residents. The citation states specifically that two Certified Nursing Assistants “placed the back of [a resident’s] bra strap over the wheelchair handle when the resident was exhibiting behavioral symptoms and constantly trying to stand up from the wheelchair.” The citation states further that one of those CNAs was captured on the facility’s video surveillance pushing a resident “to sit back in his wheelchair.” A plan of correction undertaken by the facility included the interview, suspension, investigation, and termination of both CNAs.

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Westchester Center for Rehabilitation and Nursing received 40 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. That figure is eight greater than the statewide average of 32. The Mount Vernon nursing home’s citations resulted from a total of three inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not meet quality of care standards. Section 483.25 of the Federal Code states that nursing homes must ensure that residents “receive treatment and care in accordance with professional standards of practice” and based on comprehensive assessments of each individual. According to a July 17, 2019 inspection, the nursing home did not ensure proper treatment and care for three residents. An inspector found that one resident did not receive “timely treatment and care for complaints of pain” resulting from their fall from a lift; another did not receive timely treatment and care for a bedsore/pressure ulcer on their left heel; and a third was not provided prompt medication, per a physician’s orders, for their “critically elevated potassium levels.” The citation describes these failures as resulting in the “potential to cause more than minimal harm” to residents.

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Williamsbridge Center for Rehabilitation and Nursing received 29 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. These citations include one that authorities determined to reflect “a severe, systemic deficiency.” The Bronx nursing home’s citations resulted from a total of four inspections by state authorities. The violations they describe include the following:

1. The nursing home did not provide an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide an environment as free as possible from accident hazards, and to provide proper supervision to prevent accidents. A citation issued on April 23, 2019 found that the nursing home failed to adequately supervise a resident with a history of attempted elopement, who eloped from the facility on April 5, 2019. According to the citation, the resident was not accounted for during an 11 AM head count, and the nursing home did not launch a search for the resident until 2:30 PM. As of the date of the citation, the resident’s whereabouts remained unknown. The Department of Health found that this failure resulted in “immediate jeopardy to resident health or safety” and reflected a systemic deficiency.

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Sapphire Nursing and Rehab at Goshen received 49 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 Goshen nursing home’s citations resulted from a total of eight surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not properly implement procedures to prevent residents from eloping. Section 483.25 of the Federal Code requires nursing home facilities to provide residents with “adequate supervision and assistance devices to prevent accidents,” including unsafe wandering off the facility’s premises. A June 2019 citation found that Sapphire Nursing and Rehab at Goshen did not ensure one resident was adequately supervised. The citation states that the resident had been assessed at low risk for elopement, but that the facility did not reassess the resident’s supervisory needs after the resident “behavior changes potentially related to increased risk for elopement.” The resident, according to the citation, “exited the building undetected, passing thorough a supervised common room and a supervised lobby, when the assigned staff were distracted by residents that required immediate attention in each of those areas.” The citation goes on to state that the resident was discovered by staff about 20 minutes afterward, then escorted back into the facility. This deficiency, according to the citation, had the “potential to cause more than minimal harm.”

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Sapphire Nursing at Meadow Hill received 42 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 facility has also been the subject of a 2011 fine of $72,000 in connection to findings during a 2009 inspection that it violated health code provisions regarding mistreatment and neglect, pressure ulcers, resident dignity, resident well-being, nurse aid competency, and administrative practices and procedures. The Newburgh 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 ensure residents were free from significant medication errors. Section 483.45 of the Federal Code ensures nursing home residents the right to be “free of any significant medication errors.” A May 2019 citation found that Sapphire Nursing at Meadow Hill did not ensure its residents were free of such. An inspector specifically found that one Licensed Practical Nurse “did not administer medications prescribed by the physician” to 12 residents. A plan of correction undertaken by the facility included the suspension of that LPN, whose employment with the facility later ended. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Grandell 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 5, 2020. The facility has also been the subject of a 2018 fine of $12,000 in connection to findings during a 2018 inspection that it violated unspecified health code provisions; a 2016 fine of $16,000 in connection to findings during a 2013 inspection that it violated health code provisions regarding quality of care, administration, and quality assessment and assurance; a 2011 fine of $34,000 in connection to findings that it violated health code provisions regarding medically related social services, accident hazards, resident well-being, administration, and hydration; and a 2010 fine of $2,000 in connection to findings that it violated health code provisions regarding quality of care and nutrition. The Long Beach 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 ensure residents were protected from abuse. Section 483.12 of the Federal Code requires nursing homes to ensure residents’ right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A May 2018 citation found that Grandell Rehabilitation and Nursing Center did not ensure this right for one resident. The citation states specifically that one of the facility’s Recreation Aides “intentionally threw water” at a resident with a redacted diagnosis. The citation states that the RA admitted to throwing water at the resident. A plan of correction undertaken by the facility included the termination of the staff member in question.

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