Articles Posted in Nursing Home Violations

Boro Park Center for Rehabilitation and Healthcare received 31 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 7, 2019. The facility was also the subject of a 2018 fine of $10,000 in connection to “multiple deficiencies” described in a December 2017 survey. The Brooklyn nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not provide adequate care and services to sustain the resident’s highest practicable well-being. Section 483.24 of the Federal Code requires that nursing homes provide each resident with “the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care.” A December 2017 citation found that the nursing home failed to provide services in accordance with professional quality standards. An inspector specifically found that a resident had received numerous physician orders that “were not carried out,” such as orders directing blood tests, urine tests, and outpatient surgery. The citation notes that a facility Medical Doctor twice examined the resident but “did not document resident status or MD recommendations” on the resident’s record. The citation states that these failures resulted in the potential delay of care for a leak in the resident’s feeding tube. The survey referenced in this citation was the survey resulting in the 2018 fine of $10,0000 against Boro Park Center for Rehabilitation and Healthcare.

2. The nursing home did not protect residents from accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities must maintain an environment as free as possible from accident hazards, and provide adequate supervision and assistive devices to prevent residents from experiencing accidents. A July 2019 citation found that the resident failed to provide adequate supervision to residents. An inspector specifically found that the nursing home failed to adequately monitor a resident who left the premises “undetected by staff.” According to the citation, the resident was discovered missing at 10:30 PM on the evening in question, and was later returned from the home of one of his emergency contacts. As a result of the incident, the Certified Nursing Assistant who reported him missing was suspended, and the resident was placed on wander guard and re-assessed as at high risk of elopement.

Cypress Garden Center for Nursing and Rehabilitation received 20 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 violations they describe include the following:

1. The nursing home did not provide adequate supervision or assistive devices to prevent residents from falling. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments remain “as free of accident hazards as is possible” and to provide residents with “adequate supervision and assistance devices to prevent accidents.” An October 2016 citation found that Cypress Gardens did not ensure that a resident who had been identified as “High Risk” for falls received adequate supervision to prevent them. An inspector specifically found that in June 2016 the resident was observed on the floor after a fall, having “sustained abrasions to the forehead and left forearm.” According to the citation, the resident’s care plan interventions for falls included a chair alarm, but at the time he “did not have a bed or chair alarm in pace.” The citation found that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not implement proper measures to prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to maintain 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 September 2019 citation found that the nursing home failed to provide such in an instance when an eye doctor consulting at the facility “did not properly clean the overbed table used or perform hand hygiene prior to completing an eye exam.” An inspector observed the eye doctor wiping off an exam table with a paper towel and then placing his equipment bag on it while there were still “stains” on the table; the doctor then moved the table into a resident’s room, according to the citation, and performed an eye exam on the resident without performing hand hygiene beforehand, although he was observed performing hand hygiene afterward.

Franklin Center for Rehabilitation and Nursing received 26 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 three inspections by state authorities. The deficiencies they describe include the following:

1. The facility did not adequately implement measures to prevent and heal pressure ulcers. Section 483.25 of the Federal Code states that nursing homes must prevent residents with “care, consistent with professional standards of practice, to prevent pressure ulcers.” A November 2017 citation found that Franklin Center for Rehabilitation and Nursing did not ensure the provision of professional standards of care to a resident suffering from a Stage 4 pressure ulcer. The citation states specifically that a nurse applied to the wound “a dressing appliance that was too small,” and employed an “improper technique” to dry the resident’s pressure wound. According to the citation, the nurse applied gauze that only partially covered the wound, leaving its border as well as some “excoriated redness” exposed. The citation states that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not adequately protect residents from abuse and 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 July 2019 found that the nursing home did not protect this right in an instance in which residents sustained an injury during a “resident-to-resident altercation.” According to the citation, the altercation specifically resulted in one resident experienced “a laceration to her right leg that required sutures,” and another “was punched in the head by another resident and suffered a headache and poor vision.” The facility undertook a plan of correction relating to this incident that included the education of licensed nurses on the facility’s Resident to Resident Abuse policy, as well as the adoption of a Behavior Monitoring policy.

Meadow Park Rehabilitation and Health Care Center received 27 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 facility was also the subject of a 2017 fine of $4,000 in connection to findings it did not provide residents with an environment free of accident hazards. The Flushing nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home facility did not implement adequate measures to prevent residents from sustaining accidents. Under Section 483.25 of the Federal Code, nursing homes must ensure residents have an environment “as free of accident hazards as is possible.” An October 2016 citation states that the nursing home failed to protect all 135 of its residents from the risk of experiencing “burns and scalding” resulting from “excessive hot water temperatures from the facility’s domestic hot water system.” An inspector found specifically that the water in 17 resident rooms were “extremely hot,” and in fact “so hot that the surveyors had to remove their hands.” A reading found that the hot water temperatures in resident bathrooms and shower units ranged from 127 degrees Fahrenheit to 137 degrees Fahrenheit, whereas the “acceptable temperature range” was 90 degrees to 120 degrees. This deficiency, which was connected to the 2017 fine of $4,000, was found to have resulted in “Immediate jeopardy to resident health or safety.”

2. The nursing home did not keep residents free from abuse and neglect. Section 483.12 of the Federal Code requires nursing homes to protect their residents’ right to freedom from “abuse, neglect, misappropriation of resident property, and exploitation.” A March 2018 citation found that the nursing home failed to comply with this sanction in an instance in which a Certified Nursing Assistant “willfully neglected to provide care and services” to a resident who was “incontinent of bowel and used incontinence briefs.” The citation specifically states that when the resident’s family requested on three instances that the Assistant “change the resident’s soiled incontinence brief,” the Assistant willfully declined to do so, resulting in “the resident sitting in a soiled diaper” for more than two hours.

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.”

Waterview Nursing Care Center 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 facility was also the subject of a 2010 fine of $4,000 in connection to findings it failed to comply with health code provision concerning accidents and administrative practices. The Flushing 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 employ adequate measures to protect residents from abuse. Under Section 483.12 of the Federal Code, nursing home residents have the right to be free from abuse and neglect. A May 2019 citation found that Waterview Nursing Care Center failed to prevent residents from abuse in an instance in which one resident hit another resident with his wheelchair’s footrest. According to the citation, the resident who was hit “suffered a laceration and bleeding to his head,” and was subsequently transferred to a local hospital for care. The resident received four staples on his head before returning to the facility. A plan of correction undertaken by the facility included the transfer of the aggressor to another unit and his placement on regular visual checks.

2. The nursing home did not ensure its residents’ drug regimens were free from unnecessary medications. Under Section 483.45 of the Federal Code, nursing homes must maintain “each resident’s drug regimen… free from unnecessary drugs.” According to a November 2016 citation, Waterview Nursing Care Center did not ensure one resident’s drug regimen was free of unnecessary medications. An inspector specifically found that the resident was administered an antipsychotic medication even tough the facility did not have “documented evidence of non- pharmacological interventions being attempted prior to [the medications] administration.” In an interview, the facility’s psychiatrist said that the medication should not have been administered without documented evidence of such.

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.

Oceanview Nursing & Rehabilitation Center received 30 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 2009 fine of $2,000 in connection to findings it violated health code provisions regarding accidents. The Far Rockaway 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 provide necessary care to promote the prevention and healing of pressure ulcers. Under Section 483.25(c) of the Federal Code, nursing homes must offer residents adequate treatment and services to promote the healing of pressure ulcers and bedsores, and to ensure that residents admitted without such do not develop them unless their condition renders it unavoidable. A January 2019 citation found that Oceanview Nursing & Rehabilitation Center did not ensure two residents were provided with necessary treatment and services to prevent the development of pressure ulcers. An inspector observed specifically that a Licensed Practical Nurse did not follow a physician’s order to treat a resident’s wound with dry gauze, instead treating it with a saline-soaked gauze pad. An inspector also observed another resident on two separate instances not wearing heel boots in accordance with a physician’s orders. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

2. The nursing home did not provide residents with necessary treatment and devices to maintain hearing and vision. Section 483.25 of the Federal Code requires that nursing homes must ensure that residents “receive proper treatment and assistive devices to maintain vision and hearing abilities,” including by facilitating scheduling of and transportation to specialist appointments if necessary. A May 2016 citation found that the nursing home failed to ensure it addressed an ophthalmologist’s recommendation for one resident. An inspector specifically found that there was no documented evidence that the resident was seen by a retinologist, per the ophthalmologist’s recommendation. In an interview, the facility’s nurse practitioner stated that she misread the ophthalmologist’s consult, and as such did not know that the ophthalmologist had recommended the resident see a retinologist.

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