Articles Posted in Nursing Home Violations

New Glen Oaks Nursing Home received 34 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Glen Oaks nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not ensure the potential for accidents was adequately minimized. Under Section 483.25 of the Federal Code, nursing homes must provide residents with adequate supervision to prevent accidents, and further ensure an environment as free as possible from accident hazards. An August 2017 citation found that New Glen Oaks Nursing Home did not provide an adequately accident-free environment, with an inspector specifically observing “an uncapped soiled razor… in an open box on top of [a] resident’s bedside table.” In an interview, the facility’s nursing supervisor stated that the facility’s Certified Nursing Assistants were “aware that razors are not to be left at residents’ bedside and should be disposed of,” and the facility’s Director of Nursing Services stated that the razor in question “should not be kept at the resident’s bedside.”

2. The nursing home did not take adequate measures to prevent the potential spread of infection. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A July 2018 citation found that New Glen Oaks Nursing Home failed to comply with this section. The citation specifically states that facility staff were observed assisting residents during mealtime “without washing or sanitizing their hands in the dining room.” For instance, a Certified Nursing Assistant was observed putting used and dirty trays on a rack, then cutting up a resident’s food, then pouring water into a cup and giving it to the resident, all without washing or sanitizing her hands. The citation describes this deficiency as “widespread” and as having the “potential to cause more than minimal harm.”

Queen of Peace Residence received 12 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The Queens Village nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from 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 March 2018 citation found that Queen of Peace Residence failed to protect residents from neglect. An inspector specifically found that a resident was “left unattended for 1 1/2 hours on a commode which was located in the resident’s room in an area where the resident’s call bell was not within reach.” A Certified Nursing Assistant stated that on the morning in question, her responsibility was to “cover the floor,” ensure “all residents go to Mass in the Chapel,” and then stay in the facility’s TV room with residents not attending mass; the resident in question was suffering from a cold and staying in her room, according to the CNA, who said “her mistake was that she did not knock on the door to… see if she was in her room.” Another CNA—who had covered for the first CNA while she was on break—had not informed her “that she put the resident on her commode,” according to the citation, which noted that disciplinary actions were administered to the CNAs involved and that CNAs and nursing staff were subsequently educated.

2. The nursing home did not adequately implement its infection control practices. Section 483.80 of the Federal Code requires nursing homes to create and implement “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A March 2018 citation found that Queen of Peace Residence did not ensure staff followed its infection control practices. An inspector specifically found that a Registered Nurse “used a contaminated glove to smear ointment on a resident’s wound” during one resident’s pressure ulcer care. In an interview, the RN acknowledged that she used the incorrect technique, stating that “it was wrong to apply the ointment on the resident’s buttocks after contamination of the glove” and that she had to improve her treatment technique.

Queens Nassau Rehabilitation and Nursing Center received 11 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The facility has also received two fines: one $10,000 fine in April 2018 over findings of multiple health code violations; and one $20,000 fine in November 2011 over findings it violated health code provisions regarding quality of care and physician visits. The Far Rockaway nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not proper follow infection prevention and control policies and procedures. Under Section 483.80 of the Federal Code, nursing home facilities must design and execute “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment” for residents. An August 2018 citation found that Queens Nassau Rehabilitation and Nursing Center did not ensure staff performed “proper hand hygiene between residents to prevent the spread of infections.” An inspector specifically observed a Licensed Practical Nurse administering medications without performing hand hygiene. An inspector also observed the Licensed Practical Nurse in question assisting a resident with care and opening medication for another resident without performing hand hygiene in between. The citation states that this “deficient practice was observed on multiple occasions.”

2. The nursing home did not ensure the provision of services by qualified persons in accordance with residents’ plans of care. Section 483.21 of the Federal Code requires that “services provided or arranged” by nursing home facilities and outlined in residents’ comprehensive care plans must be “provided by qualified persons in accordance with each resident’s written plan of care.” An April 2017 citation found that the nursing home did not ensure one resident received services in accordance with their plan of care. The citation specifically states that while the resident had been ordered by a physician to wear a right hand mitten, the resident was observed not wearing such. The mitten was intended to prevent the resident from pulling out their feeding tube, according to the citation, which notes that a Certified Nursing Assistant said in an interview that she “was under the assumption that as long as the resident is calm the mitten does not have to be on.”

Park Nursing Home received 39 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 3, 2020. The Rockaway Park nursing home’s citations resulted from a total of eight inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not ensure residents were protected from abuse. Under Section 483.12 of the Federal Code, nursing homes must ensure their residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A February 2019 citation found Park Nursing Home did not ensure its residents remained free from abuse. The citation specifically found that “a cognitively impaired resident who displays physical aggression towards others physically assaulted more than one resident, one more than one occasion.” An inspector found that whereas the facility implemented interventions to address this resident’s conduct, these interventions “were not evaluated for their effectiveness.” A Director of Nursing stated in an interview that these interventions included separating the resident from others, close monitoring, and placing him with residents able to defend themselves; the DON said also that “these interventions were not all documented and should have been.”

2. The nursing home did not provide residents adequate supervision to prevent elopement. Section 483.25 of the Federal Code requires that nursing homes provide residents with “adequate supervision and assistance devices to prevent accidents.” An October 2018 citation found that Park Nursing Home did not adequately supervise a resident who had been “identified at risk for elopement” and who refused to wear a wander guard device. The citation goes on to state that the resident eloped the facility after climbing its back gate without staff knowledge; it notes specifically that the Registered Nursing Supervisor was not notified of the elopement until approximately three hours after it occurred, and the resident was returned after another two hours. The citation notes that the elopement was attributed in part to “a breach in security,” and the facility’s plan of correction included the termination of a security officer “who left his post.”

In just three years, the number of nursing home monitors in New York declined a whopping 37 percent. According to Utica’s Observer-Dispatch, this sharp decline leaves the number of nursing home monitors at less than half of the state’s mandatory minimums. According to elder care advocates, the number of monitors is now so low that the state could run afoul of the federal Older Americans Act.  

According to state Comptroller Thomas DiNapoli, funding cuts from the state are the primary cause of the shortage. In New York, like many other states, the nursing home monitoring program (also called an ombudsman program) is comprised of both paid state employees and volunteers. While the number of volunteer monitors has remained constant in the last decade, the number of paid monitors has declined. In 2019, only 50 paid staffers were left to cover 900 facilities. In comparison, 600 long-term care facilities have volunteer monitors. Sadly, the nursing homes that are most in need of monitoring appear to the ones stretched thin when it comes to sharing ombudsman.

The reduced access to nursing home monitors causes “many residents… a very diminished quality of life,” volunteer ombudswoman, Sue Schafer told the newspaper. The program provides nursing home residents and patients weekly access to people who are not employed by their facility and can listen to their concerns and advocate on their behalf. Perhaps more importantly, nursing home monitors are responsible for observing a nursing home’s conditions and reporting any suspicious activities or potential abuse. 

Concord Nursing and Rehabilitation Center received 44 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The facility also received a 2016 fine of $14,000 in connection to findings it violated health code provisions regarding administration and respiratory care. The Brooklyn 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 supervision to

. Section 483.25 of the Federal Code requires nursing homes to provide residents with “adequate supervision and assistance devices to prevent accidents.” An August 2018 citation found that Concord Nursing and Rehabilitation Care did not adequately supervise residents who had been identified as at risk for elopement. The citation specifically found that a resident “was not provided with [a] wander guard” as per a physician’s order, and further that no documentation in the resident’s records indicated they were being supervised “to prevent unsafe wandering and/or elopement.” Although the resident had a physician order specifying for a wander guard on their left hand, according to the citation, when an inspector asked a Certified Nursing Assistant if the resident had one, none was found. The CNA stated in an interview that “the resident is confused and sometimes removes the wander guard,” and further that “there is no daily record monitoring the use of wander guard.”

Crown Heights Center for Nursing and Rehabilitation received 26 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The facility also received a 2012 fine of $10,000 in connection to findings it violated health code provisions regarding quality of care care; and a 2011 fine of $10,000 in connection to findings it violated health code provisions regarding accidents and supervision, administration, professional services, and significant medication errors. The Brooklyn 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 ensure residents’ drug regimens were free of unnecessary drugs. Under Section 483.45 of the Federal Code, nursing homes must keep “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that Crown Heights Center for Nursing and Rehabilitation did not ensure a resident’s drug regimen was free of unnecessary drugs. The citation specifically found that the resident had been prescribed a certain medication absent a psychiatric evaluation, and “with no evidence of behaviors to support ongoing use” of the medication in question. The citation notes that the resident’s records contained no documentation indicating that they had been assessed by a psychiatrist or that the facility attempted a gradual dose reduction of the medication since the resident’s admission. A plan of correction undertaken by the facility included a psychiatric consult and an order to discontinue the medication.

2. The nursing home did not provide residents with adequate accident supervision. Section 483.25 of the Federal Code states that nursing homes must ensure residents receive adequate supervision and devices to prevent accidents. A March 2017 citation found that the nursing home did not provide each resident with adequate supervision and functioning equipment. The citation notes specifically that “a suction machine not being properly equipped for use in case of emergency” was observed in a dining room. An inspector observed the suction machine unplugged against the wall, with no tubing connected to it, and with no suction tip. When an inspector asked for a demonstration of the machine’s use, neither of two Licensed Practical Nurses were “able to attached [sic] the tubing to the machine,” with one leaving to retrieve correct tubing. The citation states that 15 minutes passed before the machine was properly ready for use, concluding that it “was not equipped for immediate use in the event of an emergency.”

Dr. Susan Smith McKinney Nursing and Rehabilitation Center received 17 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The facility also received a 2019 fine of $4,000 in connection to findings of multiple deficiencies observed in a February 11, 2019 survey. The Brooklyn 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 ensure residents’ freedom from abuse. Under Section 483.12 of the Federal Code, nursing home residents have the right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A February 2019 citation found that the nursing home did not ensure staff provided residents with services necessary to avoid “physical pain, mental anguish, or emotional distress.” The citation found specifically that one of the facility’s Certified Nursing Assistants tied a resident’s left hand to bed rails using a plastic bag, resulting in psychosocial harm for the resident, “who was totally dependent on staff for all care needs, an unable to call for assistance or help.” The citation also states that another CNA “rough handled” another resident while trying to provide care. A plan of correction undertaken by the facility included the removal of the CNAs in question.

2. The nursing home did not ensure residents’ right to freedom from physical restraints. Sections 483.10 and 483.12 of the Federal Code provides nursing home residents with the right to be “free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms.” A February 2019 citation found that facility staff unnecessarily used physical restraints to inhibit a resident’s freedom of movement. The citation specifically describes a Certified Nursing Assistant tying a resident’s hand to their bed rail with a plastic bag, stating later that “she restrained the resident because he became resistive as she tried to clean feces from his hand.” The citation notes that the resident had no orders to be restrained and that the CNA was allowed by the facility to continue providing the resident with care for two days following the incident. A plan of correction undertaken by the facility states that the CNA as well as a Registered Nurse who “did not report the incident to facility administrative staff” in a timely manner were both removed from the facility. The citation also notes that the incident resulted in “actual harm” to the resident in question.

King David Center for Nursing and Rehabilitation received 44 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The Brooklyn 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 resident drug regimens were free from unnecessary drugs. Section 483.45 of the Federal Code requires nursing homes to keep “each resident’s drug regimen… free from unnecessary drugs,” including drugs used in excessive duration and/or without adequate monitoring. An April 2019 citation found that King David Center for Nursing and Rehabilitation did not monitor a resident receiving anticoagulant therapy injections for symptoms and side effects of such. The citation notes specifically that the resident informed staff he had “bruising all along [the] lower quadrant of his stomach” and that he receives bruising whenever he receives the anticoagulant injections. The citation also states that notes kept by staff who administered the medication did not contain any documentation of the resident’s skin discoloration or bruising. In an interview, the resident’s MD stated that he would begin documenting the bruises, although he said they were not a cause for major concern.

2. The nursing home did not provide residents with a safe, clean, comfortable, and homelike environment. Section 483.10 of the Federal Code stipulates that nursing home residents have a right to a safe, clean, comfortable, and homelike environment. An April 2019 citation found that the nursing home did not ensure such, specifically observing that 6 resident rooms with “various signs of disrepair.” These signs included a room with cracked and broken wood along its entrance wall; rusted paint on an air conditioner cover; peeling and faded paint under a bathroom sink; faded paint on an air conditioner cover that was improperly affixed to the room’s wall; windows taped shut with duct tape; a fist-sized hole in a bathroom door; and a radiator that was not affixed to the wall. The citation states that these deficiencies had “potential to cause more than minimal harm.”

Buena Vida Continuing Care & Rehab Center received 23 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The Brooklyn 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 take adequate measures to prevent accidents. Section 483.25 of the Federal Code requires nursing home facilities to remain “as free of accident hazards as is possible” and to provide residents with adequate supervision and assistance to prevent accidents. An August 2019 citation found that Buena Vida Continuing Care & Rehab did not ensure one of its residents was free of accident and injury. The citation specifically found that the resident was served a dinner tray that included two cups of hot water. The resident was attempting to prepare tea when one of the cups spilled hot water onto her thighs, causing her to sustain an injury. The citation states that there was no documented instructions for facility staff regarding safe water temperatures when reheating water in the microwave, and that the incident resulted in “actual harm” to the resident.

2. The nursing home failed to ensure residents’ drug regimens were free from unnecessary medications. Section 483.45 of the Federal Code requires nursing homes to keep “each resident’s drug regimen… free from unnecessary drugs.” A May 2019 citation found that Buena Vida Continuing Care & Rehab used Valporic acid to treat a resident’s anxiety disorder and another unspecified condition “without ordering labs to monitor the Valporic acid levels” in the resident. The citation states that there was no evidence lab work was performed to test and monitor the acid levels, and notes that the facility’s Medical Director stated in an interview that “labs should have been done on the Valporic acid levels at least every 6 months even as a baseline.”

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