Articles Posted in Nursing Home Violations

Cayuga Nursing and Rehabilitation Center has received 96 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received fines totaling $36,000 in connection to findings that it violated health code provisions concerning resident rights, accidents, quality of care, pressure ulcers, food standards, administrative practices, and more. The Ithaca 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 infection-control procedures. Section 483.80 of the Federal Code stipulates that nursing homes must create and maintain an infection control program so as to stave off the development and transmission of disease. A June 2019 citation found that Cayuga Nursing and Rehabilitation Center did not ensure such. The citation describes the facility’s staff’s failure to “follow proper infection control technique during a skin treatment observation,” specifically describing failures to wipe down equipment, perform hand hygiene, and use proper equipment. The equipment goes on to state that the facility did not employ proper infection control technique while administering medication to seven residents, specifically describing a nurse who did not perform hand hygiene between each resident’s medication administration. A plan of correction undertaken by the facility included the re-education of the nurse in question.

2. The nursing home did not employ adequate measures to care for pressure ulcers. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with necessary treatment and services to prevent and/or heal pressure ulcers. A December 2017 citation found that Cayuga Nursing and Rehabilitation Center did not ensure such for one resident. The citation specifically describes a resident who was identified on admission as having a Stage II pressure ulcer, but “was not re-assessed timely and she was not provided with pressure relief interventions as planned to promote healing.” A plan of correction undertaken by the facility included the education of relevant staff and the revision of the resident’s plan of care.

Beechtree Center for Rehabilitation and Nursing has received 65 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received a 2016 fine of $10,000 in connection to findings in a 2012 inspection that it violated health code provisions concerning abuse, accidents, staff treatment of residents, and administrative practices. The Ithaca nursing home’s citations resulted from a total of nine surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not employ adequate measures to prevent infection. Section 483.80 of the Federal Code requires nursing homes to mitigate the risk of infection via the creation and maintenance of an infection control program. An August 2019 citation found that Beechtree Center for Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the facility did not maintain infection control standards during a resident’s pressure ulcer dressing change. It goes on to describe the facility’s failure to “provide appropriate personal protective equipment (PPE) or a way to perform hand hygiene in the soiled laundry sorting area; and washers and dryers were not maintained according to the user manual.” The citation describes these deficiencies as having the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the re-dressing of the resident’s pressure ulcer and the placement of PPE in the laundry room.

2. The nursing home did not adequately supervise residents. Section 483.25 of the Federal Code requires nursing homes to provide residents with adequate supervision to prevent accidents. An August 2019 citation found that Beechtree Center for Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the facility had no plan in place to address the resident’s smoking. it goes on to state that the resident in question “was observed smoking independently after he had been assessed by the facility to be a safety risk and not eligible for safe-smoking.” The resident, who is described as having “impaired tactile sensation, did not light his own cigarette safely and was likely to drop smoking material.” According to the citation, he flicked ashes onto the ground and threw cigarette butts on the ground but “was not able to put them out.” An assessment found that the resident “was a safety risk and was not eligible for a safe-smoking contract.” A plan of correction undertaken by the facility included the facility’s provision, to the resident, of a smoking alternative.

Washington Center for Rehabilitation and Healthcare has received 49 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The facility has also received a total of $74,000 in fines in connection to findings that it violated health code provisions concerning infection control, accidents, medication errors, resident behavior, hydration, administration, and more. The Warsaw 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 physical abuse. Section 483.12 of the Federal Code grants nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A January 2020 citation found that Washington Center for Rehabilitation and Healthcare failed to ensure this right for two residents. The citation specifically states that it did not ensure the two residents “were free from physical abuse related to a resident to resident altercation.” It describes an incident in which one resident attempted to pull another resident’s wheelchair “and was swinging a fist at the resident,” who in response “used his reacher and struck” the resident “twice in the face,: at which point a staffer separated the residents. A plan of correction undertaken by the facility included a rooming change for the residents, who were roommates.

2. A November 2019 citation also found that Washington Center for Rehabilitation and Healthcare did not protect residents from abuse. The citation specifically describes a Registered Nurse Supervisor assaulting a resident. According to the citation, the RNS instructed two other staffers to to hold the resident’s hands while the RNS placed medication crushed into pudding into the resident’s mouth. Per a written statement, one of those staffers said “that RNS #1 had instructed LPN #1 and CNA #1 to hold Resident #1’s hands, then put medication into his/her mouth. When RNS #1 put the medication in Resident #1’s mouth, she tipped his/her head back and put her hand in front of his/her mouth.” A plan of correction undertaken by the facility included the suspension, investigation, and termination of the RNS.

Wyoming County Community Hospital Skilled Nursing Facility has received 40 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The facility has also received a total of $16,000 in fines in connection to findings that it violated health code provisions concerning accidents, quality of care, and administrative practices. The Warsaw 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 adequately prevent and control infection. Per Section 483.80 of the Federal Code, nursing home facilities must create and uphold an infection prevention and control program so as to help prevent the transmission of disease and infection. A February 2019 citation found that Wyoming County Community Hospital did not ensure such. The citation states specifically that the facility did not care for a resident’s pressure ulcer “using appropriate infection control technique.” It goes on to describe a nurse packing the resident’s wound with gauze when “the gauze fell out of the wounds and onto the bed.” The nurse proceeded to pick up the gauze and put it back in the wounds, then remove her soiled gloves and don clean ones. “While the LPN was trying to apply the resident’s mesh underwear the gauze pads fell out onto the bed again,” the citation states, after which the nurse picked them up and put them back in the wounds, then after the procedure removed her gloves and washed her hands. In an interview, the facility’s Registered Nurse Unit Coordinator said that “staff should wash their hands between each treatment,” and that “if the packings fall out of the wound, she would expect the nurse to start the treatment again.” In another interview, the facility’s infection prevention nurse “said that the nurses should perform hand hygiene before starting a dressing change and after removing the soiled dressings.”

2. A July 2016 citation also found that Wyoming County Community Hospital did not adequately maintain an infection control program. The citation specifically describes two resident units that “had issues involving the lack of proper transportation of soiled linens.” It goes on to describe an observation of a shower unit in which there were resident clothes, an afghan, towels, and soiled washcloths on the wet floor. According to the citation, a Certified Nursing Assistant carried the soiled linens out of the room, and they were observed making contact with her personal clothing as she “proceeded to walk down the hall to the soiled utility room and discarded the soiled items in the linen hampers.” In an interview, the facility’s Registered Nurse Educator said that “staff are taught to wear gloves and carry soiled linens away from their body and are supposed to observe universal precautions.”

East Side Nursing Home has received 11 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The Warsaw 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 adequately prevent medication errors. Under Section 483.25 of the Federal Code, nursing homes are required to “ensure that residents are free of any significant medication errors.” A September 2016 citation found that East Side Nursing Home failed to ensure such for three residents. The citation is heavily redacted but indicates “issues” that involved the administration of a medication “and signing for another dosage” to one resident, as well as “interim physician orders” for two other residents. It goes on to describe confusion involving the physician’s orders for one resident, and the administration of a significant medication without an order. A plan of correction undertaken by the facility included the review of physician’s orders for each of the residents.

2. The nursing home did not implement adequate measures to prevent infection. Section 483.80 of the Federal Code requires the establishment and maintenance by nursing home facilities of “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment” for residents. A January 2018 citation found that East Side Nursing Home did not ensure such. The citation specifically describes the facility’s failure to “conduct water sampling for Legionella every 90 days for the first year of their sampling plan.” According to a review of the nursing home’s sampling reports, only two samples had been taken in its potable water system during the year in question. In an interview, the facility’s Supervising Administrator “stated that the sampling company was supposed to come in and sample in December, but they did not make it.” A plan of correction undertaken by the facility included the drafting of a policy and procedure to “address the management of the legionella testing compliance.”

Penn Yan Manor Nursing Home has received 14 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The Penn Yan nursing home’s citations resulted from a total of two surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately supervise residents. Section 483.25 of the Federal Code requires nursing homes to provide residents with “adequate supervision and assistance devices to prevent accidents.” A November 2019 citation found that Penn Yan Manor Nursing Home failed to ensure such for one resident. The citation states specifically that the resident did not receive adequate supervision to prevent her from eloping from the facility undetected and falling outside, after which her care plan “was not revised to include an actual elopement.” The citation goes on to describe the nurse turning off an alarm at the nurse’s station, after which the resident exited the facility undetected, and later being found sitting on the ground by a staffer from a “neighboring facility,” who brought her back. In an interview, the nurse in question said “she thought she was resetting the alarm at the nurses’ station when she turned it off.” A plan of correction undertaken by the facility included the re-education of staff on the nurses’ station alarm system.

2. The nursing home did not adequately prevent medication errors. Section 483.45 of the Federal Code stipulates that nursing homes must ensure their medication errors rates do not meet or exceed five percent. A November 2019 citation found that Penn Yan Manor Nursing Home did not ensure such for two residents. The citation states specifically that one resident’s eye drops “were administered in both eyes instead of one eye,” and the other “had a medication ordered after meals that was given over an hour after meals.” A plan of correction undertaken by the facility included the re-education of nurses on medicine administration and the disciplining of one nurse.

Wayne Health Care has received 23 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The Newark 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 measures to prevent accidents. Under Section 483.25 of the Federal Code, nursing homes must ensure resident environments are kept “as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.” A November 2016 citation found that Wayne Health Care did not ensure such. The citation states specifically that the nursing home did not comply with requirements concerning oxygen tanks and smoking. It goes on to describe a resident who “confessed that he removes his oxygen while lighting his cigarette and then replaces the nasal cannula into his nose,” causing the surveyor concern for the resident’s safety. In an interview, the facility’s Director of nursing “stated that she was aware of the resident’s non-compliance with smoking and they did not consider a wanderguard.” A plan of correction undertaken by the facility included the counseling of the resident regarding the nursing home’s smoking-free policy.

2. The nursing home did not take adequate steps to prevent infections. Section 483.65 of the Federal Code mandates that nursing homes must “establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.” A November 2016 citation found that Wayne Health Care did not ensure such. The citation states specifically that the nursing home “was unable to provide evidence of a complete infection control program that investigates, controls, and prevents infections in the facility, and did not maintain a record of incidents and corrective actions related to infections.” The citation describes this deficiency as having the “potential to cause more than minimal harm.”

Wayne County Nursing Home has received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The Lyons 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 infection control measures. Section 483.80 of the Federal Code requires, among other things, that nursing homes create and maintain a program to prevent and control infection and maintain a sanitary environment for residents. A June 2017 citation found that Wayne County Nursing Home failed to ensure such. The citation states specifically that the nursing home did not have proper data analysis for infections, did not properly implement infection control techniques in connection to one resident’s incontinence care, failed to prevent a transfer sling and oxygen concentrator from becoming soiled, and failed to prevent the soiling of resident’s toilet seat and bathroom wall. 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 in-servicing of all staff on infection control, hand hygiene, personal protective equipment policy and equipment cleaning.

2. The nursing home did not adequately care for pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with necessary services to prevent the development of pressure ulcers and to promote the healing of pressure ulcers. A November 2016 citation found that Wayne County Nursing Home failed to ensure such. The citation specifically describes a “lack of communication regarding skin breakdown, lack of timely assessment, documentation, and treatment of” a resident’s pressure ulcer. A plan of correction undertaken by the facility included the review of all residents’ skin assessments over the prior 30 days to determine whether they received proper treatment.

Evergreen Commons Rehabilitation and Nursing Center has received 64 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 5, 2020. The facility also received fines totaling $30,000 in connection to findings that it violated health code provisions regarding quality of care, accidents, and more. The East Greenbush 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 maintain an adequate infection prevention and control program. Under Section 483.80 of the Federal Code, nursing homes must endeavor to provide residents with a safe and sanitary environment, one that helps mitigate the development of communicable diseases and infections, by establishing and upholding an infection prevention and control program. An August 2019 citation found that Evergreen Commons Rehabilitation and Nursing Center failed to ensure such for two residents. The citation specifically describes in which a Licensed Practical Nurse, while changing a resident’s wound dressing, did not remove her gloves, wash her hands, or don new gloves after touching the outside of a spray bottle and a gauze package. In an interview, the nurse stated that “she should not have touched the outside of the dressing packages and touch the dressing contents without first removing her gloves, washing her hands and putting on another pair of gloves.” The citation also describes an instance in which a a nurse, while assisting with a dressing change by holding a resident’s leg up, put the resident’s heels down on a cushion in contravention of policy. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

2. The nursing home contravened garbage disposal code. Section 483.60 of the Federal Code requires nursing homes to “dispose of garbage and refuse properly.” An August 2019 citation found that Evergreen Commons Rehabilitation and Nursing Center failed to ensure such. The citation states specifically that the resident’s trash compactor “was leaking liquid waste and the door of the compactor was left open.” In an interview, the facility’s Director of Food Service said he would have the compactor serviced, and that he would reeducate employees to close the door after use.

Eddy Memorial Geriatric Center has received 24 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 5, 2020. The Troy 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 proper measures to mitigate the risk of infection. Section 483.80 of the Federal Code stipulates that nursing homes must “establish and maintain an infection prevention and control program” designed to ensure residents a “safe, sanitary and comfortable environment.” A May 2020 citation found that Eddy Memorial Geriatric Center did not ensure such for one resident. The citation states specifically that the facility did not ensure the completion of hand-washing after resident care, and that “multi-resident use equipment was cleansed after use on a resident and prior to returning item to a clean area to prevent the risk cross-contamination.” It goes on to describe an oximeter that was not cleansed according to policy requiring that it be “cleansed with disinfecting agent, super Sani-wipes after each use and remain on the nursing medication cart”; according to the citation, a nurse placed it on the medication cart without first cleansing it. A plan of correction undertaken by the facility included the reeducation of the nurse in question..

2. A December 2019 citation also found that Eddy Memorial Geriatric Center did not follow infection control code. This citation describes the facility’s failure to ensure infection control precautions were followed during a resident’s dressing change for an unstageable decubitus ulcer on their left great toe. The citation goes on to state that a separate resident was not provided with one tissue for each of their eyes following the administration of eyedrops. The citation describes these deficiencies as having the “potential to cause more than minimal harm to residents.”

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