Articles Posted in Nursing Home Violations

Hollis Park Manor Nursing Home received 39 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 10, 2020. The Hollis 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 implement adequate (bedsore) pressure ulcer care. Section 483.25 of the Federal Code requires nursing homes to provide residents with a level of treatment and services that prevents the infection of pressure ulcers. An August 2018 citation found that a resident did not receive the necessary care and treatment to prevent the infection of a sacral pressure ulcer. An inspector specifically observed that “there was no dressing observed to the sacral area” on the resident’s ulcer” during care. In an interview, a Certified Nursing Assistant stated that he had removed the dressing while changing the resident; in another interview, a Licensed Practical Nurse stated that CNAs “are not to remove any dressings,” and to inform nurses if dressings become soiled or fall off the wound.

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Holliswood Center for Rehabilitation and Healthcare received 28 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 9, 2020. The Hollis 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 implement proper infection control practices. 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 December 2017 citation found that Holliswood Center for Rehabilitation and Healthcare failed to maintain infection prevention and control procedures during the care of resident wounds. The citation specifically notes that while a Licensed Practical Nurse caring for a resident’s bedsore / pressure ulcer, she was observed removing and discarding soiled dressing, removing her gloves, and then washing her hands “using improper technique” before donning new gloves and cleaning the wound. The technique in question involved using “very little lather” while putting her soapy hands under running water.

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Bridge View Nursing Home received 38 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 9, 2020. The facility also received a 2017 fine of $16,000 in connection to findings in an April 2016 survey that it violated health code provisions regarding unnecessary drugs, physician supervision, quality of care, and treatment of residents. The Whitestone 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 abuse. 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 December 2018 citation found that the nursing home did not ensure one resident was free from physical abuse. The citation found specifically that one of the facility’s Licensed Practical Nurses observed a Certified Nursing Assistant slap a resident’s face and then punch the resident in the head, while other residents were present, in the facility’s dining area. A plan of correction undertaken by the facility included the removal from duty of the CNA in question.

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A recent report published by Harvard University shows much lower staff levels at nursing homes across the country than previously reported. The author of the study, Fangli Geng, says that a recent change in how nursing homes report their staffing levels shows that up to 70 percent of nursing homes had previously overreported the number of staff between April 2017 and March 2018. The faulty reporting was almost exclusively confined to weekends, especially when counting registered nurses or RNs.

The author of the study point to the more accurate form of reporting currently used by the government. Previously, the number of nurses on staff at a nursing home would be calculated by using the payroll data in the month immediately preceding a health inspection visit. Because nursing home inspections usually occurred around the same time each year, nursing homes apparently increased their staff levels around this time. As part of the Affordable Care Act, nursing homes were required to transmit all payroll data to the federal government – providing a more accurate and complete understanding of nursing staff levels. 

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Caring Family Nursing and Rehabilitation 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 January 9, 2020. The Far Rockaway 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 take adequate steps to prevent accidents. Section 483.5 of the Federal Code stipulates that nursing homes must ensure resident environments are as free as possible of accident hazards. A December 2018 citation found that Caring Family Nursing did not ensure an environment free of accident hazards, specifically finding that an electric laundry iron was observed on a bedside table in the facility’s third floor nursing unit. According to the citation, the resident in question had “severe cognitive impairment.” In an interview, the facility’s Registered Nurse told an inspector “she had never seen the iron before and did not know who it belonged to,” while the resident said that “he did not know who the iron belonged to” either. A plan of correction undertaken by the facility included the iron’s disposal and the implementation of a visitor bag search policy.

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Bezalel Rehabilitation and Nursing Center received 25 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 9, 2020. The Far Rockaway 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 ensure residents’ drug regimens were free from unnecessary psychotropic medications. Section 483.45 of the Federal Code requires that nursing homes keep residents’ drug regimens free from the unnecessary use of any drugs that affect “brain activities associated with mental processes and behavior. A June 2019 citation found that Bezalel Rehabilitation and Nursing Center did not ensure a resident properly received gradual dose reductions to discontinue the use of a psychotropic medication. The citation states specifically that the resident was admitted to the nursing home already receiving the medication, but the facility did not attempt a gradual dose reduction, and “there was no evidence that the resident displayed any mood or behavioral symptoms that warranted continued use of the medication without a GDR attempt.” The citation states further that the nursing home did not attempt, before the resident was admitted, to confirm their psychiatric history.

2. The nursing home did not maintain an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with an environment as free as possible from accident hazards, and with adequate supervision to ensure that residents do not experience accidents. A June 2016 citation found that the nursing home did not take adequate accident prevention measures with respect to one resident who had planned monitoring for swallowing difficulty and aspiration precautions. According to these citations, the precautions included “being observed while eating, sitting upright while eating and for at least 30 minutes after eating, never eat in bed and if resident experiences coughing or secretions, during or without meal hold the feed till totally clear.”

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Highland Care Center received 31 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 10, 2020. The Jamaica 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 (bedsore) pressure ulcer care. Section 483.25 of the Federal Code requires nursing homes to ensure that residents receive “care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable.” A May 2019 citation found that Highland Care Center did not ensure a resident with a pressure ulcer received adequate care. An inspector specifically found that the resident’s pressure-relieving device for their foot/leg ulcer was “missing” and “not in place.” A Certified Nursing Aide stated in an interview that the resident’s heel booties had been sent to the laundry and should have been returned the following day, but when she checked the laundry they weren’t there; “she did not report this to her nurse,” the citation states. A plan of correction undertaken by the facility included nursing staff in-service education and the provision of new heel booties to the resident.

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Resort Nursing Home 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 9, 2020. The facility was also the subject of a 2010 fine of $2,000, in connection to findings of health code violations related to nutrition. The Arverne 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 adequate care to promote the healing of pressure sores (bedsores). Section 483.25 of the Federal Code stipulates that home facilities must provide residents with adequate treatment and services to promote the healing of pressure ulcers and bedsores. According to a November 2015 citation, Resort Nursing Home did not provide one resident with necessary treatment for such. The citation states specifically that the resident was provided with “incorrect treatment to his right heel.” The resident had five ulcers, according to the citation, and an inspector observed a wound nurse provide treatment to one of them in a manner that was not in accordance with the physician’s orders. The citation notes that this deficiency had the “potential to cause more than minimal harm,” and the facility noted that it potentially affected all residents with pressure ulcers.

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The Pavilion at Queens received 11 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 four inspections by state authorities. The violations they describe include the following:

1. The facility did not ensure the professional care and services of residents’ pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to provide residents with “care that is consistent with professional standards of practice” to promote the healing of pressure injuries / ulcers. A May 2018 citation found that The Pavilion at Queens failed to comply with this section in connection to one resident’s care. An inspector specifically found that a nurse employed improper technique when tending to a resident’s wound dressing, using one hand to peel off the dressing instead of two hands, and touching gauze to the mouth of a saline bottle—which the citation states could risk infection transmission—rather than pouring the saline out of the bottle onto the gauze. The citation states that this deficiency had the “Potential to cause more than minimal harm.”

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NYS Veterans Home in NYC 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 13, 2019. The facility was also the subject of three fines from the Department of Health: a 2016 fine of $2,000 in connection to findings the facility did not comply with health code provisions concerning accident hazards; a 2015 fine of $10,000 in connection to findings it did not comply with health code provisions regarding quality of care; and a 2010 fine of $6,000 in connection to findings it did not comply with health code provisions regarding social services, accidents, and administrative procedures. The Jamaica nursing home’s citations resulted from a total of three inspections by state authorities. The violations they describe include the following:

1. The nursing home did not adequately ensure the prevention and control of infection. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program” that provides residents with a safe and sanitary living environment. A January 2018 citation found that NYS Veterans Home in NYC did not ensure its staff performed proper hand hygiene practices. An inspector specifically observed one of the facility’s Licensed Practical Nurses “handling sterile supplies with soiled gloves.” According to the citation, the LPN, while wearing gloves, put a sterile drape on the resident’s chest, then moved the resident’s garbage clan closer to her. She was then observed removing the gloves and putting on a new pair of gloves, but did not wash her hands or otherwise clean them with an alcohol-based solution. The citation states that this deficiency resulted in the “potential to cause more than minimal harm.”

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