Articles Posted in Nursing Home Violations

Westchester Center for Rehabilitation and Nursing received 40 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. That figure is eight greater than the statewide average of 32. The Mount Vernon nursing home’s citations resulted from a total of three inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not meet quality of care standards. Section 483.25 of the Federal Code states that nursing homes must ensure that residents “receive treatment and care in accordance with professional standards of practice” and based on comprehensive assessments of each individual. According to a July 17, 2019 inspection, the nursing home did not ensure proper treatment and care for three residents. An inspector found that one resident did not receive “timely treatment and care for complaints of pain” resulting from their fall from a lift; another did not receive timely treatment and care for a bedsore/pressure ulcer on their left heel; and a third was not provided prompt medication, per a physician’s orders, for their “critically elevated potassium levels.” The citation describes these failures as resulting in the “potential to cause more than minimal harm” to residents.

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Williamsbridge Center for Rehabilitation and Nursing received 29 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. These citations include one that authorities determined to reflect “a severe, systemic deficiency.” The Bronx nursing home’s citations resulted from a total of four inspections by state authorities. The violations they describe include the following:

1. The nursing home did not provide an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide an environment as free as possible from accident hazards, and to provide proper supervision to prevent accidents. A citation issued on April 23, 2019 found that the nursing home failed to adequately supervise a resident with a history of attempted elopement, who eloped from the facility on April 5, 2019. According to the citation, the resident was not accounted for during an 11 AM head count, and the nursing home did not launch a search for the resident until 2:30 PM. As of the date of the citation, the resident’s whereabouts remained unknown. The Department of Health found that this failure resulted in “immediate jeopardy to resident health or safety” and reflected a systemic deficiency.

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Sapphire Nursing and Rehab at Goshen received 49 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The Goshen 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 properly implement procedures to prevent residents from eloping. Section 483.25 of the Federal Code requires nursing home facilities to provide residents with “adequate supervision and assistance devices to prevent accidents,” including unsafe wandering off the facility’s premises. A June 2019 citation found that Sapphire Nursing and Rehab at Goshen did not ensure one resident was adequately supervised. The citation states that the resident had been assessed at low risk for elopement, but that the facility did not reassess the resident’s supervisory needs after the resident “behavior changes potentially related to increased risk for elopement.” The resident, according to the citation, “exited the building undetected, passing thorough a supervised common room and a supervised lobby, when the assigned staff were distracted by residents that required immediate attention in each of those areas.” The citation goes on to state that the resident was discovered by staff about 20 minutes afterward, then escorted back into the facility. This deficiency, according to the citation, had the “potential to cause more than minimal harm.”

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Sapphire Nursing at Meadow Hill received 42 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The facility has also been the subject of a 2011 fine of $72,000 in connection to findings during a 2009 inspection that it violated health code provisions regarding mistreatment and neglect, pressure ulcers, resident dignity, resident well-being, nurse aid competency, and administrative practices and procedures. The Newburgh 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 ensure residents were free from significant medication errors. Section 483.45 of the Federal Code ensures nursing home residents the right to be “free of any significant medication errors.” A May 2019 citation found that Sapphire Nursing at Meadow Hill did not ensure its residents were free of such. An inspector specifically found that one Licensed Practical Nurse “did not administer medications prescribed by the physician” to 12 residents. A plan of correction undertaken by the facility included the suspension of that LPN, whose employment with the facility later ended. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Grandell Rehabilitation and Nursing Center received 22 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 5, 2020. The facility has also been the subject of a 2018 fine of $12,000 in connection to findings during a 2018 inspection that it violated unspecified health code provisions; a 2016 fine of $16,000 in connection to findings during a 2013 inspection that it violated health code provisions regarding quality of care, administration, and quality assessment and assurance; a 2011 fine of $34,000 in connection to findings that it violated health code provisions regarding medically related social services, accident hazards, resident well-being, administration, and hydration; and a 2010 fine of $2,000 in connection to findings that it violated health code provisions regarding quality of care and nutrition. The Long Beach 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 ensure residents were protected from abuse. Section 483.12 of the Federal Code requires nursing homes to ensure residents’ right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A May 2018 citation found that Grandell Rehabilitation and Nursing Center did not ensure this right for one resident. The citation states specifically that one of the facility’s Recreation Aides “intentionally threw water” at a resident with a redacted diagnosis. The citation states that the RA admitted to throwing water at the resident. A plan of correction undertaken by the facility included the termination of the staff member in question.

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Beach Terrace Care Center received 33 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The Long Beach 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 take adequate measures to care for residents’ bedsores/pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing home facilities must ensure residents receive the necessary care and services to promote the healing of pressure ulcers and bedsores. A May 2019 citation found that Beach Terrace Care Center did not comply with this section. An inspector found specifically that the nursing home “did not perform a timely assessment when a resident’s skin condition changed.” The resident in question had an open blister on their left heel, however, the facility had no documented evidence that this blister was assessed until two days after it was identified. According to this citation, although a Skin Assessment Sheet was filled out to inform the facility’s Wound Care Nurse, no note was written in the resident’s chart at the time it was identified. The citation states that this deficiency had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the education of facility nursing staff on new procedures for documenting skin impairments.

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Highfield Gardens Care Center of Great Neck received 32 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 5, 2020. The Great Neck 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 provide adequate pressure ulcer care. Section 483.25 of the Federal Code requires nursing homes to provide treatment and services consistent with professional practices to promote the healing of pressure ulcers, heal infection, and prevent new ulcers from developing. A January 2019 citation found that Highfield Gardens Care Center of Great Neck did not ensure such for one resident with a Stage IV sacral pressure ulcer. The citation specifically states that a Licensed Practical Nurse “did not provide treatment consistent with current standards of practice in the maintenance of infection control.” The citation goes on to state that the LPN dressed the resident’s wound and went to wash his hands, at which point the dressing fell off the wound and onto the resident’s briefs. The LPN then put the dressing back on the wound, according to the citation, and when asked by an inspector if the dressing “that he picked up was clean” was unable to answer. In an interview, a Registered Nurse stated that the “dressing that fell on the resident’s brief was not clean and the whole treatment had to be re-done.”

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Long Beach Nursing and Rehabilitation Center received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 5, 2020. The Long Beach 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 provide adequate treatment and care for residents’ pressure ulcers / bedsores. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents receive “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” The citation states specifically that while a resident’s care plan interventions provided for the offloading of their heels “in bed with pillows and to have a Roho cushion when in the gerichair,” a surveyor observed the resident in his bed with his feet resting on a mattress, and in a gerichair without the Roho cushion. A plan of correction undertaken by the facility included the education of the Certified Nursing Assistant “who failed to follow the resident’s plan of care.”

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Mayfair Care Center received 42 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 6, 2020. The Hempstead 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 take adequate measures to protect residents from abuse. Section 483.12 of the Federal Code provides nursing home residents with “the right to be free from abuse.” A July 2018 citation found that Mayfair Care Center did not ensure this right for one resident. The citation states specifically that the resident wandered into the room of another resident “with a history of physically abusive behavior,” who then pushed the first resident to the floor, resulting in a redacted medical condition and transfer to the hospital. The citation notes that this deficiency resulted in the occurrence of “actual harm.”

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Nassau Rehabilitation & Nursing Center received 26 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 6, 2020. The facility has also been the subject of a 2018 fine of $10,000 in connection to findings during a 2017 inspection that it violated unspecified health code provisions; a 2016 fine of $2,000 in connection to findings during a 2012 inspection that it violated health code provisions regarding pressure sores; and a 2014 fine of $6,000 in connection to findings in a 2011 inspection that it violated unspecified health code provisions. The Hempstead 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 implement adequate accident-prevention measures. Section 483.25 of the Federal Code requires nursing homes to ensure resident environments are “as free as accident hazards as is possible.” A June 2019 citation found that Nassau Rehabilitation & Nursing Center did not ensure such for two residents. The citation states specifically that clothing in two resident rooms “was observed hanging from the wall extension arm lamps, including hanging from the lamp light switches.” In an interview, the facility’s Director of Nursing Services said of one of the resident rooms that “the resident should not be hanging clothes on the lamp and we should ensure clothing is not hung from the lamp.” A plan of correction undertaken by the facility included the removal and proper storage of the clothing in question, and the ordering of an additional storage rack for one of the residents.

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