Articles Posted in Nursing Home Violations

Park Terrace Care Center received 30 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The facility was also the subject of a 2017 fine of $2,000 in connection to findings in a December 2016 survey that it did not provide adequate pressure ulcer care. The Rego Park nursing home’s citations resulted from a total of four inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not provide adequate treatment and services for residents’ pressure ulcers and bedsores. Section 483.2 of the Federal Code requires nursing homes to residents persons who enter without pressure sores from developing them unless their condition renders such unavoidable; and that residents with pressure sores receive treatment and services adequate to promote their healing. A December 2016 citation found that Park Terrace Care Center did not properly assess and evaluate a resident who was admitted to the facility “with intact skin and a discoloration” on their left foot. The resident subsequently developed an “unstageable pressure ulcer,” according to the citation, which goes on to state that whereas the resident’s plan of care provided for the wearing of a left air boot “at all times after the pressure ulcer was identified,” this provision was not followed by staff. The citation states that this deficiency in the facility’s treatment and care resulted in “actual harm” to the resident.

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Queens Boulevard Extended Care received 16 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The Woodside nursing home’s citations resulted from a total of three inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not provide adequate treatment and services to promote the prevention and healing of pressure ulcers and bedsores. Section 483.25(c) of the Federal Code stipulates that nursing home facilities must provide treatment and services to promote the healing of pressure injuries / ulcers, and to ensure that residents admitted without pressure ulcers do not develop them unless medically unavoidable. An August 2019 citation found that Queens Boulevard Extended Care did not provide a resident with a level of treatment and services consistent with professional standards to promote the healing of their ulcers. An inspector specifically found that the facility did not implement the use of pressure relieving devices for a resident who had bilateral heel wounds. The inspector observed a Registered Nurse performing wound care treatment to both of the resident’s feet, but without putting pressure relieving devices in place after completing the wound care. A review of care records did not find any “documented evidence for the application of the use of heel protectors while in bed,” although facility policy provided for the use of pressure relief assistive devices in instances when pressure relief was warranted.

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DRY Harbor Nursing Home received 25 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The Maspeth 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 ensure necessary treatment and care of bedsores / pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to ensure that residents with pressure ulcers receive “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” A January 2019 citation found that one of DRY Harbor Nursing Home’s Licensed Practical Nurses “did not practice acceptable standards and wound care techniques” for a resident suffering from a stage 3 pressure injury. Among other findings, an inspector observed the LPN removing the resident’s diaper and rubbing the wound site with gauze after running saline over the wound, contravening the best practice of patting areas dry to prevent tissue damage. The inspector also observed the LPN applying “two parallel strip amounts” of medical creams a gauze strip, instead of mixing the creams together. According to the citation, the LPN then put the same diaper back on the resident, later informing the inspector that “using a clean diaper would have been referable in keeping with infection control practices.”

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Silvercrest received 19 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 13, 2019. The Jamaica 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 take adequate measures to prevent residents from sustaining falls. Section 483.25 of the Federal Code requires nursing homes to ensure that residents receive supervision to prevent them from sustaining accidents. According to a September 2018 citation, Silvercrest did not adequately supervise one resident, resulting in the resident falling. An inspector specifically found that the resident, who had been “assessed as a high risk for falls,” was left unattended in one of the facility’s hallways, and sustained a fall. When the resident was found by staff, she was observed suffering from “pain and swelling of the left shoulder” and transferred to a local hospital for examination.

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The federal government unveiled a new tool last month for families to see if a nursing home facility was recently accused of abuse. The government-run Nursing Home Compare website, which aggregates nursing home safety information from across the country, will now flag nursing homes which have credible allegations of abuse reported to authorities in the last 12 months. A “small icon” of a “red circle with a white hand inside” will show up next to the name of the nursing home facility whenever it is searched for on the government website. 

Nursing home advocates say the change is minor but long overdue. Studies show that as many as one in 20 nursing home patients are abused and the problem is rarely reported. Already, more than 5 percent of the nursing homes have been branded with the icon warning of abuse allegations, representing facilities with 1.4 million residents. Families who want more information on the allegations of nursing home abuse can look at the entries on inspection reports. The Wall Street Journal details one example where two wheelchair-bound residents with dementia got into a fight and staffers at the Pennsylvania nursing home chose not to intervene. The fight ended when a 95-year-old man died. Another example reported by the national newspaper involves a Maryland nursing home where health inspectors found maggots in the face wound of a dying cancer patient. Both facilities will now have red warning icons next to their name on the government website. 

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US News & World Report released their annual rankings for 15,000 nursing homes across the country. The ratings are calculated using data on staffing, success in preventing emergency room visits and repeat hospitalizations, the rates of pneumonia and flu immunizations, antipsychotic use, and other factors. Rankings for each nursing home are calculated both for “short-term” performance and “long-term” performance. 

Here’s how local nursing homes stacked up against the competition, according to LoHud.com

High Performing in both Long-Term Care and Short-Term Care:

Park Gardens Rehabilitation & Nursing Center received 38 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 21, 2019. Those citations number six more than the statewide average of 32. The Bronx nursing home’s citations resulted from a total of three inspections by state authorities. The violations they describe include the following:

1. The nursing home did not ensure its residents’ drug regimens were free from unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing homes must maintain “each resident’s drug regimen… free from unnecessary drugs,” going on to clarify that “unnecessary” refers to any drug used in excessive dosage, for excessive duration, without adequate monitoring or indications, and/or in the presence of adverse consequences. A March 2017 citation found that Park Gardens Rehabilitation and Nursing Center failed to comply with this section in two separate capacities. In one, the facility did not provide “adequate monitoring” of a diabetic resident who had recently received an increase in their insulin dosage, so as to figure out whether the increase was effective or yielded any ill effects. Separately, the citation notes, the nursing home increased another resident’s dosage of an unidentified medication “without documentation for the reason of the increase.” The citation states that these failures resulted in the “potential to cause more than minimal harm” to residents.

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The Emerald Peek Rehabilitation and Nursing Center received 31 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The Peekskill nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing did not provide treatment and services of a degree adequate to ensure prevention and/or healing of pressure ulcers. Section 483.25 of the Federal Code requires nursing home facilities to offer residents “care, consistent with professional standards of practice, to prevent pressure ulcers” from developing and to heal existing pressure ulcers. A January 2019 citation found “no evidence” that when a resident developed a pressure ulcer, the facility undertook actions to get rid of risk factors connected to pressure ulcer development. In response to the citation, the facility implemented a plan of correction that included weekly risk assessment and intervention audits to ensure the proper execution of preventative measures for pressure ulcer development.

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United Hebrew Geriatric Center received 24 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The New Rochelle nursing home’s citations resulted from a total of five inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did ensure residents were protected from abuse. Section 483.12 of the Federal Code stipulates that nursing home facilities must protect their residents’ “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” According to an August 2017 citation, the nursing home did not properly supervise its staff to identify or prevent abuse, follow up on abuse prevention education to ensure its compliance, or ensure the reporting of abuse to the facility’s administrator. As such, according to the citation, the facility did not prevent “repeated” physical and emotional abuse of a resident with dementia and dysphagia. The citation describes video evidence that showed nursing staff forcefully feeding the resident, who had a swallowing disorder, and who “grimaced” and “expressed a fearful look” during the feeding. The citation also notes that a Registered Nurse entered the room during one incident and observed a Certified Nursing Assistant “feeding and handling the resident in a rough manner,” but “did not intervene to protect the resident.” The citation identified this deficiency as a pattern of conduct that posed immediate jeopardy to resident health or safety.”

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King Street Home received 32 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The Port Chester 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 take adequate steps to protect residents from abuse. Under Section 483.12 of the Federal Code nursing homes must ensure residents’ “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A July 2019 citation found that King Street Home did not ensure residents’ right to be free from abuse in an instance where a Certified Nursing Assistant was accused of being “rough” with a resident. After the resident reported the allegation, the assistant was removed from contact with that resident, but was not promptly removed from contact with other residents while the allegation was investigated. In an interview, the facility’s administrator told an inspector that the assistant “should have been removed from all resident contact” in addition to the resident in question.

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