Articles Posted in Nursing Home Violations

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Fordham Nursing Home and Rehabilitation Center has received a total of 15 citations since 2017 for violating public health code on more than one occasion.

Fordham Nursing and Rehabilitation Center received 15 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 14, 2022. The Bronx nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing homes must ensure residents receive necessary care and services to prevent the development of pressure ulcers. A December 2019 citation found that Fordham Nursing and Rehabilitation Center failed to ensure such. The citation specifically describes a resident who was “observed on multiple occasions without heel booties or diabetic shoes,” devices meant to prevent pressure ulcers, as ordered by the physician. In an interview, a Certified Nursing Assistant said that “it is not a regular occurrence for the resident to be without her heel booties.” In another interview, a Registered Nurse said she was unable to find the resident’s diabetic shoes in the resident’s room. A plan of correction undertaken by the facility included the application of the shoes to the resident and the location of the heel booties, as well as a notation on the resident’s care plan that “the blue heel booties were to be worn at all times when the resident is in bed and diabetic shoes are to be worn when the resident is out of bed.”

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East Haven Nursing and Rehabilitation Center has received a total of 16 citations from three separate state inspections since 2017.

East Haven Nursing & Rehabilitation Center received 16 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 14, 2022. The Bronx nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not take adequate steps to prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with “adequate supervision and assistance devices to prevent accidents.” A February 2020 citation found that East Haven Nursing & Rehabilitation Center failed to ensure such. The citation specifically states that after a resident receiving one-on-one supervision suffered a fall in her room, there was no investigation initiated. The citation goes on to state that the resident had suffered “3 or more falls” in the previous three months, and had been assessed as at high risk for falls. In an interview, the facility’s Assistant Director of Nursing said that an accident report indicated that “resident was found on the floor and not that the 1:1 aide assigned to the resident actually witnessed the fall,” despite the aide’s duty to “constantly” supervise and observe the resident. The ADNS added that he believed an investigation was conducted “but cannot provide any information as to how the resident was found on the floor when a 1:1 aide was scheduled to be watching her.” A plan of correction undertaken by the facility included the education of the ADNS by the Director of Nursing. 

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Fort Tryon Center for Rehabilitation has received 20 citations since 2017 for failing to prevent medication errors, failing to protect its residents from being verbally abused by staff members, and for not taking the proper precautions needed to prevent infections.

Fort Tryon Center for Rehabilitation and Nursing received 20 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 14, 2022. The Manhattan nursing home’s citations resulted from a total of eight inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent medication errors. Under Section 483.25 of the Federal Code, nursing homes must keep residents “free of any significant medication errors.” A June 2021 citation found that Fort Tryon Center failed to ensure such. The citation states specifically that three residents “were ordered to take nothing by mouth” despite a physician’s orders for medications to be administered to them by mouth. A plan of correction undertaken by the facility included the review, clarification, and revision of MD orders for the residents in question, as well as the education of licensed nurses on matters including the verification of physician orders. 

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Campbell Hall Rehabilitation Center has received a total of 77 citations since 2017 for being of violation of public health code and for failing to properly care for their residents.

Campbell Hall Rehabilitation Center received 77 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 7, 2022. The facility was recently placed on the Centers for Medicare and Medicaid Services’ list of “Special Focus Facilities” candidates, meaning it has a record of serious citations. The Campbell Hall nursing home’s citations resulted from a total of 15 inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate pressure ulcer care. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with necessary care and treatment to promote the healing of pressure ulcers. An August 2021 citation found that Campbell Hall Rehabilitation Center failed to ensure such for one resident. The citation states specifically that the resident’s records contained “no consistent documentation… to prove that that interventions and treatments were administered in accordance with the written care plan, and physician’s orders.” In interviews, facility nurses said that they conducted wound treatment but neglected to record it, with one saying that they “sometimes overlook signing treatments” in the resident’s records. A Certified Nursing Assistant said in one interview that she had observed the resident’s wound deteriorating and accordingly reported this to a nurse. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Warren Center for Rehabilitation and Nursing has received over 70 citations for being in violation of public health code since 2017 and has been fined a total of $14,000 since 2011.

Warren Center for Rehabilitation and Nursing has received 73 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 7, 2022. The facility has additionally received three fines totaling $14,000 since 2011, the most recent being a $10,000 fine issued in December 2017. The Queensbury 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 adequately prevent the use of unnecessary medications. Section 483.45 of the Federal Code stipulates that nursing home residents’ drug regimens “must be free from unnecessary drugs.” A September 2021 citation found that Warren Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically that one resident received an opioid pain medication even though their medical record did not include a clinical indication supporting its use, nor documentation to support an increase in dosage. In an interview, one of the facility’s Certified Nursing Assistants said that “they did not provide non-pharmacological interventions for pain management for this resident and the resident was not care planned for specific interventions for the nurse assistants to provide.” A plan of correction undertaken by the  facility included the re-education of licensed nurses on policy regarding medication administration.

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Since 2017, Buffalo Center for Rehabilitation and Nursing has received over 100 citations and a total of four fines for being in violation of public health code and failing to protect its residents.

Buffalo Center for Rehabilitation and Nursing has received 118 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on December 31, 2021. The facility has additionally received four fines totaling $38,000 since 2008, the most recent being a $10,000 fine issued in July 2021. The Buffalo nursing home’s citations resulted from a total of 14 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home failed to 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 2021 citation found that Buffalo Center for Rehabilitation and Nursing failed to ensure such. The citation specifically describes an incident in which a Certified Nursing Assistant entered a resident’s bathroom while the resident was in it, after which the resident “became agitated, an altercation ensued, and [the CNA] slammed the door causing the resident to fall to floor.” The resident was subsequently sent to the hospital and returned with conditions redacted by the citation. In a separate instance described by the citation, another resident was discovered on their floor of their room with bruising on their left eye and forehead. Although the resident had been assessed as at risk for falls, the citation states, there was no floor mat beside their bed as provided for by their care plan. The citation states that these deficiencies caused “actual harm.”

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A recent report by the Wall Street Journal found that elderly people living in nursing homes, care facilities, or in the care of their family members have been experiencing more abuse since the start of the Covid-19 pandemic.

The Covid-19 pandemic has “stoked” the spread of elder abuse, according to a recent report by the Wall Street Journal. Citing findings by the Federal Bureau of Investigation and a study by Yale University researchers, the report observes that “the number of elder-fraud victims increased 55% between 2019 and 2020,” while more than 20% of seniors living in private residences “reported abuse in April and May 2020,” during the early pandemic lockdowns. That figure itself represents “an 83.6% increase over pre-pandemic prevalence estimates.” Continue reading

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Recent investigations found that a nursing home in Long Island, NY had released a resident to the hospital where nurses discovered this patient was covered in wounds and his leg needed to be amputated.

A recent investigation by ProPublica examines why for-profit nursing home operator Sentosa Care has become New York’s biggest nursing home group in recent years despite its “record of repeat fines, violations and complaints for deficient care in recent years.” The key reason, according to the report: systemic failures in the state’s review and approval process for people and entities seeking to purchase shares in nursing home facilities.

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A California nursing home was fined nearly $1 million dollars after a visit by inspectors lead to the shocking discovery that Fresno’s Northpointe Healthcare Center’s patients were in danger due to overworked staff failing to properly care for residents and administer medication.

A new investigation by CalMatters asks why a nearly-$1 million fine issued against a California nursing home over alleged health code violations went unknown by consumers. In 2018, state health inspectors visited the facility, Fresno’s Northpointe Healthcare Center, and found it to have health and safety deficiencies that put its residents in “immediate jeopardy.” These included a resident “hospitalized with sepsis after missing four doses of an antibiotic,” overworked staff missing treatments and failing to administer medication, and residents suffering from bedsore-related pain. After the state inspectors released their findings, federal authorities fined the facility $912,404, reportedly “the largest penalty given to any California nursing home in at least a decade.”

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Throgs Neck Rehabilitation and Nursing Center in the Bronx has received 22 citations in the last four years after surveys by state inspectors and has been fined $2,000 for violating health codes.

Throgs Neck Rehabilitation & Nursing Center has received 22 citations for violations of public health code between 2017 and 2021, according to records accessed on December 17, 2021. It also received a $2,000 fine in 2021 over findings it violated health code provisions. The Bronx nursing home facility’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 medication errors. Section 483.45 of the Federal Code stipulates that medication error rates at nursing homes must not be “5 percent or greater.” A September 10, 2021 citation found that Throgs Neck Rehabilitation & Nursing Center failed to ensure such. The citation states specifically that one resident “was not administered with six (6) of the prescribed medications due” during an observation. The citation states further that the Licensed Practical Nurse administering the resident’s medications did “not inform the resident that some medications were not being administered at that time.” In an interview, the LPN told a state health inspector that “the missed medications were not available in the medication cart and they should have informed the resident.” The LN added that they planned to search for the medications or contact the facility’s pharmacy to confirm when the medications were re-ordered, or to re-order them if necessary. In an interview, the facility’s Director of Nursing stated “that the nurses are supposed to follow up and get medication before they are exhausted, and they did not know why the staff are not doing that.” A plan of correction undertaken by the facility included the ed-education and in-servicing of relevant staff. 

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