Articles Posted in Nursing Home Violations

Elderwood at Lockport received 31 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 8, 2021. The facility also received a fine of $10,000 in February 2020 in connection to violations of unspecified health code provisions. The Lockport 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 steps to prevent accidents. Section 483.25 of the Federal Code requires nursing homes to keep resident environments as free as possible of accident hazards and to provide residents with adequate supervision to prevent accidents. An October 2019 citation found that Elderwood at Lockport failed to ensure such. The citation states specifically that one resident who was documented for one-to-one supervision “was left unattended in a common area,” and subsequently sustained a fall and a redacted medical injury. In an interview, the facility’s administrator said the resident was left unattended in a chair because they were sleeping, and their wasn’t any violation of the resident’s care plan. A plan of correction undertaken by the facility included a review of guidelines for one-to-one supervision of residents.

2. The nursing home did not take proper infection prevention measures. Under Section 483.65 of the Federal Code, nursing homes must establish and maintain an infection prevention and control program that helps mitigate the transmission of disease. A November 2016 citation found that Elderwood at Lockport The citation states specifically that two units “had issues that involved the lack of proper disinfection of a blood glucose monitor between resident use,” as well as with unlabeled and improperly stored resident items, and with medication being administered after staffers handled it without wearing gloves. 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 counseling of relevant staff.

An outbreak of the novel coronavirus has infected 137 residents and killed 24 at The Commons at St. Anthony, a nursing home in Auburn, New York. According to a report on syracuse.com, the outbreak began on December 21, 2020, “as a wave of post-Thanksgiving Covid-19 cases began hitting the county,” per an official overseeing the home’s operations. The outbreak has affected 47 employees. Of the residents who died, 21 died at the nursing home, while three died at the hospital. Prior to the first three deaths that were reported at the nursing home on December 29, 2020, “There had been no nursing home Covid-19 deaths in Cayuga County.” As of the report’s publication on January 9, there have been 2,650 confirmed cases in Cayuga county.

According to the report, the nursing home responded to the pandemic by requiring employees to wear “gowns, gloves and face shields at all times when working with residents,” and isolated positive cases on their own floors. Employees are tested weekly, while residents are tested “on a schedule established by the state Health Department.” An infection by state health authorities found no issues with the nursing home’s infection control policies and procedures.

Records maintained by the Health Department show that as of January 8, 2021, The Commons at St. Anthony had received 27 citations for violations of public health code between 2016 and 2020. The citations resulted from a total of six inspections by state surveyors. They include the following:

Ira Davenport Memorial Hospital suffered 28 confirmed and 1 presumed COVID-19 deaths as of January 2, 2021, according to state records. The nursing home has also received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 2, 2020. The Bath 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 adequately protect residents from accident hazards. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments are kept “as free of accident hazards as is possible” and that staff provide residents with “adequate supervision… to prevent accidents.” An April 2019 citation found that Ira Davenport Memorial Hospital failed to ensure such. The citation states specifically that one resident was not provided with sufficient protection from accidents and subsequently suffered a fall with injury. It a section describing the incident in question, the citation states that “the resident was walking in the hall, lost her balance, and fell to the floor hitting her head and sustaining a goose egg to her left forehead.” The registered nurse who documented the fall wrote that there were no fall protections in place for the resident. A plan of correction undertaken by the facility included the revision of her care plan “include the presence of safety devices, ambulation changed to assist of one due to presence of illness and 15 min checks instituted.”

2. The nursing home did not adequately protect residents from abuse. Under Section 483.12 of the Federal Code, nursing home residents are guaranteed the right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A May 2018 citation found that Ira Davenport Memorial Hospital did not ensure such for one resident. The citation states specifically that a Certified Nursing Assistant hit a resident on the resident’s left thigh after the resident grabbed the CNA’s hair. According to the citation, the facility’s policies forbade abuse, and the CNA had received abuse training. A plan of correction undertaken by the facility included the termination of the CNA.

Corning Center for Rehabilitation and Healthcare suffered 28 confirmed COVID-19 deaths as of January 2, 2021, according to state records. The facility has also received 33 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 2, 2020. The Corning nursing home’s citations resulted from a total of six surveys by three inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from accident hazards. Under Section 483.25 of the Federal Code, nursing home residents are required to be provided with an environment that is “as free of accident hazards as is possible.” A March 2018 citation found that Corning Center for Rehabilitation and Healthcare failed to ensure such when it served sliced turkey to a resident “who was on a mechanical soft diet with ground meats.” In an interview, one of the facility’s Licensed Practical Nurses stated that “according to the tray ticket, the resident should have received ground turkey, not sliced.” The facility’s Director of Food Services stated in an interview that “someone on the tray line must have made a mistake.” A plan of correction undertaken by the facility included the re-education of dietary staff.

2. The nursing home did not implement adequate measures to prevent and control infection. Under Section 483.80 of the Federal Code, nursing home facilities must “establish and maintain an infection prevention and control program designed to… help prevent the development and transmission of communicable diseases and infections.” A March 2018 citation found that Corning Center for Rehabilitation and Healthcare failed to ensure such. The citation states specifically that in connection to one resident, “there was improper incontinence care and lack of glove changing and handwashing,” and that shower stretchers used by the facility for several residents “were not clean.” A plan of correction undertaken by the facility included the cleaning of shower stretchers and the re-education of the Certified Nursing Assistant who failed to provide proper incontinent care.

The Department of Veterans Affairs has announced the decommissioning of a Georgia long-term care center following an investigation that found the nursing home was infested with fire ants. The  facility, Eagles’ Nest Community Living Center, will be permanently closed following a determination that it can’t provide an adequate setting for long-term care.

According to a report in the Atlanta Journal-Constitution, the VA intends to rebuild the nursing home, and to add more long-term care beds at a different facility west of Atlanta, the Veterans Village. As for the 34 residents living at Eagles’ Nest, they were transferred to other facilities back in April “to limit their exposure to COVID-19,” according to the AJC. Continue reading

The Riverside suffered 48 confirmed and 17 presumed COVID-19 deaths as of December 26, 2020, according to state records. The nursing home has also received 53 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on December 26, 2020. The New York 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 protect residents from abuse. Under Section 483.12 of the Federal Code, nursing home residents have a right to freedom from abuse and neglect. A June 2020 citation found that The Riverside failed to ensure such. The citation states specifically that a resident who had “dementia and a history of physical aggression” participated in four altercations with other residents after the facility transferred her to a new unit. According to the citation, the facility did not put interventions in place to address this resident’s behavior and to protect other residents in the unit. It goes on to state that one altercation resulted in a laceration to the crown of another resident’s head; a subsequent altercation resulted in the aggressor’s transfer to the hospital for evaluation. A plan of correction undertaken by the facility included the review and revision of her care plan.

2. The nursing home did not provide adequate treatment for dementia. Section 483.40 of the Federal Code requires that nursing homes provide residents suffering from dementia with “appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.” A June 2020 citation found that The Riverside failed to provide such. The citation states specifically that the facility did not take individualized interventions in response to a resident’s “increasing dementia-related behaviors that occurred after a room change,” specifically, the resident’s instigation of physical altercations with other residents, including hitting one over the head with a footrest. A plan of correction undertaken by the facility included the creation of a person-centered care plan for the resident.

A new analysis by City and State asks whether New York’s nursing home facilities are prepared for another wave of the Covid-19 pandemic. Noting that while long-term care facilities have so far accounted for about 8% of Covid-19 cases, they have comprised about 40% of US fatalities from the disease. In New York especially, there have been 27,307 total Covid-19 deaths, of which 6,967 confirmed or presumed Covid-19 fatalities took place in nursing home facilities, a number that excludes residents who died outside of the facility. While nursing homes have improved their policies and procedures when it comes to Covid-19 since the virus initially struck, City and State argues, “there are still vulnerabilities that could leave nursing-home residents and staff at risk again.”

On the positive side, nursing homes are more likely to have more consistent access to tests and personal protective equipment, the analysis suggests. Nursing homes have already been conducting regular testing of all employees, and are required to have a 60-day supply of PPE. Additionally, a state rule has been reversed that in the spring led to nursing homes accepting Covid-19 patients from hospitals, spreading the virus throughout facilities.

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A new report by the Long Term Care Community Coalition highlights “no harm” deficiencies in nursing home facilities.  “No Harm” deficiencies are citations that find a nursing home violated health code provisions in a manner that did not cause residents harm. The LTCCC argues that many such citations in fact reflect harm done to nursing home residents, and more broadly reflect systemic failures in elder care facilities. But since the citations rarely if ever result in financial penalties, the LTCCC suggests, nursing homes have no incentive to address these systemic deficiencies. The report specifically discusses citations at nursing homes in four states: Continue reading

Coler Rehabilitation and Nursing Care Center suffered 13 confirmed and 1 presumed COVID-19 deaths as of December 4, 2020, according to state records. The nursing home has also received 31 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on December 2, 2020. In July 2020, it received a fine of $30,000 in connection to unspecified findings of health code violations. The Brooklyn 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 implement policies and procedures to prevent and control infection. Section 483.80 of the Federal Code stipulates that nursing home facilities must establish and maintain “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” A May 2020 citation found that Coler Rehabilitation and Nursing Care Center failed to do so. The citation states specifically that did not follow “cohorting requirements’ laid out in state guidance related to the prevention and control of Covid-19. The guidance in question required nursing homes to maintain “protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-positive residents and non-positive residents,” and to transfer residents wither within the facility or to another facility if they cannot separate patients in their own facility. The citation goes on to state that residents who tested negative for Covid-19 were not moved out of their rooms when their roommates tested positive. A plan of correction undertaken by the facility included the movement of affected residents and the re-education of staff regarding Covid-19 policies.

2. The nursing home did not adequately control pests. Section 483.90 of the Federal Code stipulates that nursing homes must “Maintain an effective pest control program so that the facility is free of pests and rodents.” A May 2020 citation found that Coler Rehabilitation and Nursing Care Center failed to ensure such. The citation states specifically that “filth flies and fruit flies were observed flying around a 4-bed occupancy room and crawling on the surface of a resident’s personal belonging that had been removed from the room,” and that a mouse was observed in a resident’s room, running across the floor. The flies in question were observed around a pile of “soiled crumpled napkins, 3 browned bananas, an orange, and used soda cups” on the floor of a resident’s room. I nan interview, a housekeeper said it’s “difficult” for housekeepers to clean the room in question because the roommate gets agitated “and may even become physical.” In another interview, the resident’s roommate said the resident has a hoarding problem, the facility rarely cleans the room, and “There are flies everywhere and she often sees roaches in the room.” A plan of correction undertaken by the facility included the cleaning of the room and the re-education of both the resident and housekeeping staff.

Pennsylvania Governor Tom Wolf has vetoed a hotly debated new piece of legislation that would protect nursing homes from coronavirus-related lawsuits, according to recent news reports.

The bill in question passed both houses of Pennsylvania’s state legislature, though Law360 notes it passed in the General Assembly “by narrow margins.”

Governor Wolf said in a statement about the veto that the bill extended too much protection to nursing homes, schools, hospitals, and various other businesses. “This legislation provides broad, overreaching immunity from civil liability during the current pandemic,” he said. “Shielding entities from liability in such a broad fashion as provided under this bill invites the potential for carelessness and a disregard for public safety.”

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