Articles Posted in Nursing Home Violations

Crown Park Rehabilitation and Nursing Center received 37 citations for violations of New York and federal public health law between 2015 and 2019, according to records provided by the New York Department of Health and accessed on November 2, 2019. Over the course of five inspections by health authorities, the Cortland, New York nursing home received five more citations than the statewide average of 32. It also received five enforcement actions resulting in fines between 2012 until 2018. According to the Long Term Care Community Coalition, Crown Park is a “one-star nursing home,” a term that indicates it “shows evidence of significantly poor levels of care.” The nursing home’s violations found by the Department of Health include the following:

1. The nursing home failed to ensure residents were free from abuse and neglect. Section 483.12 of the Federal Code provides nursing home residents with “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A January 17, 2018 citation found, however, that the nursing home did not ensure that ten of eleven sampled residents were provided with “adequate supervision to prevent abuse.” The citation states that these residents were involved in multiple altercations with each other, and that the facility’s failure to ensure each resident’s safety resulted in the continuation of these altercations. These altercations reportedly resulted in injuries: one resident received a bruise, while another sustained a laceration and bled visibly. Although the facility’s protocol provided for a system of safety rounds to ensure its residents’ safety, “there was no documented evidence” that such a program was operated as defined. A stipulation and order dated September 18, 2018, states that alleged violations uncovered during the January 17 inspection resulted in the Department of Health’s levying of a $2,000 fine against Crown Park Rehabilitation and Nursing Center. Continue reading

Between 2015 and 2019, Adira at Riverside Rehabilitation and Nursing received 37 citations for violations of public health laws, according to records accessed on November 2, 2019. The Department of Health is the public entity responsible for inspecting nursing homes every 9 to 15 months to ensure compliance with state and federal health and safety laws. Adira at Riverside’s 37 citations, which resulted from three inspections, were five more than the statewide average of 32. The Yonkers nursing home’s citations include the following:

1. The nursing home failed to provide proper provide treatment and services sufficient to prevent and heal pressure ulcers and bedsores. A citation issued on December 2017, found that Adira at Riverside failed to ensure that one of three residents inspected was provided with appropriate care of pressure ulcers. Section 483.25 of the Federal Code requires that nursing homes provide residents with care adequate to prevent pressure ulcers unless otherwise unavoidable given their condition, and further, that residents suffering from pressure ulcers receive necessary treatment and services to prevent infection or the development of new ulcers. The Department of Health states specifically that the facility did not properly inflate an air mattress to the manufacturer’s recommended amount so as to provide the patient with “optimum pressure relief” while they were in bed. A surveyor found that whereas the resident’s weight was recorded as 109.6 pounds, the control box regulating the air mattress was set at 200 pounds, and that facility staff were unaware who had set the air pressure at that level or who was responsible for ensuring proper mattress inflation.

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New York State agreed to pay more than $6 million to victims of abuse at a state-run nursing home in The Bronx. The settlement comes after a protracted legal battle that began more than five years ago after a series of news reports detailing physical abuse and widespread neglect at the nursing home. According to The New York Times, staff members would spit on the nursing home patient’s faces, force them to take cold showers, and physically attack the helpless patients. One family member of a nursing home resident, which is known as Union Avenue I.R.A., told the newspaper that the front desk answered the phone with, “Good morning, Bronx Zoo.”

As part of the legal settlement with New York, the nursing home abuse victims forced the state to surrender control of the facility to a private nonprofit agency. “We lost all faith that the agency can run this house effectively,” the victims said in a statement to The New York Times. Indeed, the misconduct of the nursing home was not the only problem at Union Avenue I.R.A. The lawsuit describes a dysfunctional culture where anyone who reported misconduct faced retaliation. After a state investigation found 13 instances of nursing home abuse at the Bronx facility, New York State did not fire anyone. A state-mandated arbitration process protected the confidentiality of the employees and the state merely transferred the abusers to a new facility.

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In a detailed piece on Health Affairs, David G. Stevenson dissects the current issues facing the nursing home industry and the government’s role in overseeing the unwieldy, complex industry. Beginning with the failed hope of the Nursing Home Reform Act, signed into law more than 30 years ago with the purpose of ensuring nursing homes provide a safe and healthy environment, Stevenson quickly delves into the absentee government oversight that has occurred since the landmark legislation.

After the high-profile rollback of several regulations enacted during the Obama administration deemed unnecessarily punitive or ineffective, the Centers for Medicaid and Medicare Services (CMS) appears to be refocusing its efforts on the well-being of nursing home residents.

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New York nursing home regulators knew an upstate nursing home’s roof leaked for four years before finally forcing the owner to fix the safety hazard. According to, the state Health Department inspection records show reports of “water-stained ceiling tiles” and “a hose running down from the ceiling of a resident’s room into a rusty bucket” dating back in 2015 and 2016. The Health Department is responsible for inspecting nursing homes in New York every 16 months.

After noticing the leaky roof in 2015, inspectors worked with Pontiac Nursing Home to fix the ceiling tiles and the leaky roof. Despite the clearly hazardous conditions, the upstate nursing home never implemented the plan. Consequently, the ceiling was still leaking when inspectors returned in 2016. With the water collecting in a “rusty bucket,” nursing home employees assured state regulators that the slip-and-fall danger was only temporary and the leak had been fixed three months earlier.

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The federal government fined a Buffalo nursing home $47,827 for erroneously administering insulin to a resident. According to The Buffalo News, the fine against Humboldt House represents the sixth largest in New York for 2018. The newspaper reports that a physician at the nursing home administered insulin to a diabetic resident in February 2018 despite a hospital discharge report warning the nursing home staff to “PLEASE AVOID GIVING THIS PATIENT INSULIN” – in all capital letters.

The nursing home resident, who was not named by the newspaper, was found unresponsive multiple times over the next few days. After reviving the elderly woman with medication and fruit juice, the nursing home finally realized its mistake. Federal officials determined this medication error caused “actual harm” to a patient, the most serious type of violation for a nursing home.

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The New York Health Department confirmed an antibiotic-resistant ‘superbug’ was found at Palm Gardens Center for Nursing and Rehabilitation in Brooklyn. State health officials say that Candida auris, a highly contagious, drug-resistant fungus infected 38 patients at the Brooklyn nursing home. Since arriving in the United States in 2015, 800 Americans have been diagnosed with C. auris. According to public health officials, the victims of this contagious disease are typically elderly and more than half die from the disease within 90 days.

Public health officials believe that Maria Davila may have brought the ‘super bug’ into the nursing home. After arriving at the nursing home several years ago, Davila suffered from recurrent bacterial infections – which were treated with heavy doses of powerful antibiotics. During those trips in-and-out of the hospital, bacteria that responded to the medication was eradicated. C. Auris, however, is resistant to antibiotics and therefore followed Davila back to the nursing home. The contagious disease then spread to 38 other residents.

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After addressing the shortage of nursing staff in hospitals, healthcare advocates have set their sights on implementing “Safe Staffing” policies in New York’s nursing homes. Safe Staffing policies would legislate minimum levels of nursing staff across the state’s nursing homes. Currently, New York State law only requires “sufficient staffing” which grants nursing homes wide discretion to determine whether its facility has sufficient levels of staffing. Elder care advocates lobbied state legislators to include safe staffing requirements in the budget this year. Lawmakers in Albany declined their request.

Instead, lawmakers opted to study the staffing levels at nursing homes. According to The Buffalo News, the budget passed earlier this year in Albany included a directive to the New York State Health Department to begin a study on May 1 analyzing “the range of potential fiscal impacts of staffing levels, other staffing enhancement strategies, and other potential quality improvement initiatives,” according to WHEC. The health department will then issue a final report to lawmakers at the end of the year. Given the timing of the report, it appears unlikely that any legislation will pass this year establishing mandatory staffing levels at nursing homes. Studies in Albany can frequently go in two directions. In some situations, studies are meant to endlessly shelve an unpopular idea. In other circumstances, studies can empower government agencies to develop their own policy proposals that will then be quickly passed into law.

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Employees at an Illinois nursing home stole more than $750,000 from a 96-year-old woman, according to The Chicago Sun Times. After the appalling theft, the thieves are now trying to delay the nursing home patient’s lawsuit trying to recover the stolen funds. According to attorneys for the elderly woman, the former nursing home employees are deliberately stalling in hopes that the woman passes away before the lawsuit’s conclusion. “I think they’re hoping they’ll get off the hook if she dies,” Cook County Public Guardian Charles Golbert told the Chicago newspaper. Because the nursing home resident, whose name is Grace Watanabe, does not have a spouse or any children, the money was willed to two non-profits in the local area. If Watanabe were to pass away before the conclusion of the lawsuit then those organizations would have the legal right to “step in” to her shoes and finish litigating her civil lawsuit.

The judge overseeing the case is to frustrate the nursing home’s attempts at delaying the case. Last week, the judge imposed a $400 fine as part of a contempt order aimed at executives of Symphony Residents of Lincoln Park. These executives are refusing to sit down for a deposition and answer questions about the treatment of Grace Watanabe. The employees who are accused of stealing money from Watanabe, who is diagnosed with advanced stage dementia, have invoked their Fifth Amendment right against self-incrimination when asked about the alleged crimes over the past few months. Criminal charges are expected to be filed against the fraudster in the next few weeks, according to Cook County District Attorneys.
The illegal scheme to defraud Watanabe was discovered by federal authorities after the bank alerted them of suspicious withdrawals coming from the nursing home resident’s bank account. Unfortunately, this type of financial fraud is a common form of elder abuse, which has been on the rise across the country and remains sadly under-reported. Employees of a nursing home or caretakers discover the financial information of an elderly person, typically with limited cognitive abilities, and then take advantage of their position of trust by swindling the person out of their money. In this instance, it appears the lowlife criminals will not be able to get away with it, though. In addition to the $400 daily fine, which the nursing home says it will appeal, an entire community of Japanese-Americans have rallied support for Watanabe and promise to keep her case in the spotlight and hold the thieves responsible, whether Watanabe lives to see that result or not.

Webcams are becoming popular in nursing rooms across the country as families see it as an easy way to check on their loved ones and prevent neglect and elder abuse. Driven by the increased use of security cameras across the country and their reduced prices, webcams are popping up across the country and, when used discreetly, can sometimes catch cases of horrific elder abuse. The legality of webcams inside of nursing homes is sometimes questionable. A Minnesota court ruled in 2017 that a family had a right to set up a webcam in their loved one’s room after nursing home staffers kept unplugged and moving the camera – apparently not wanting to be recorded. Since 2017, seven states have passed legislation allowing families to place webcams in nursing home rooms.

While states move to legalize the use of webcams, privacy advocates have some concerns about the widespread use of webcams in elder living facilities. First, since nursing home residents are particularly vulnerable and prone to cognitive impairments then the decision to set up a webcam usually falls on their guardian or family. Given the serious privacy implications of being constantly filmed, family members would hopefully consult their loved one. Unfortunately, studies reported by Medical Xpress show that families tend to value “keeping the peace” over discussing these important matters.

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