Articles Posted in Physical Abuse

Terence Cardinal Cooke Health Care Center received 34 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 13, 2020. The facility has also been the subject of a 2011 fine of $2,000 in connection to findings during a 2010 inspection that it violated health code provisions regarding quality of care. The Manhattan 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 an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing homes must provide residents an environment as free as possible from accident hazards, and which also has adequate staff supervision to prevent accidents. A February 2018 citation found that Terence Cardinal Cooke Health Care Center did not provide one resident with necessary supervision to prevent an accident. The citation notes that the resident had been identified as at high risk for fall and injury, and that her comprehensive care plan documented that staff would monitor the resident directly when the resident was at the nursing station. In spite of this, according to the citation, the resident sustained a fall and injury at the nursing station. A Licensed Practical Nurse stated in an interview that she had not assigned anyone to monitor the resident, and that none of the six Certified Nursing Assistants on the unit witnessed the fall. In an interview, the facility’s Director of Nursing stated of the resident’s care plan documentation for monitoring while at the  nursing statement, “it has a greater chance that staff will see the resident more often, and does not mean that the resident must be on Line of Sight.”

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Oxford Nursing Home received 22 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 21, 2020. The Brooklyn 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 ensure residents’ right to freedom from abuse. Under Section 483.12 of the Federal Code, nursing home residents have a right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A January 2019 citation found that Oxford Nursing Home did not protect a resident from abuse. The citation states specifically that the nursing home’s surveillance camera captured, in July 2018, a resident spitting on a newspaper in the facility’s dining room. A Certified Nursing Assistant then grabbed the resident’s hand and “repeatedly rubbed the resident’s hand into the oral substance that the resident expectorated on the newspaper and table,” according to the citation. In an interview, the CNA in question “admitted to the actions,” and the facility’s Director of Nursing said that the facility had provided its CNAs with “no written instructions” regarding the resident’s behavior of spitting on the table. The citation found this deficiency as having the “potential to cause more than minimal harm.”

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Holliswood Center for Rehabilitation and Healthcare received 28 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 9, 2020. The Hollis 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 proper infection control practices. 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 December 2017 citation found that Holliswood Center for Rehabilitation and Healthcare failed to maintain infection prevention and control procedures during the care of resident wounds. The citation specifically notes that while a Licensed Practical Nurse caring for a resident’s bedsore / pressure ulcer, she was observed removing and discarding soiled dressing, removing her gloves, and then washing her hands “using improper technique” before donning new gloves and cleaning the wound. The technique in question involved using “very little lather” while putting her soapy hands under running water.

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Bridge View Nursing Home received 38 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 9, 2020. The facility also received a 2017 fine of $16,000 in connection to findings in an April 2016 survey that it violated health code provisions regarding unnecessary drugs, physician supervision, quality of care, and treatment of residents. The Whitestone nursing home’s citations resulted from a total of seven surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from abuse. Section 483.12 of the Federal Code requires nursing homes to ensure each resident’s “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A December 2018 citation found that the nursing home did not ensure one resident was free from physical abuse. The citation found specifically that one of the facility’s Licensed Practical Nurses observed a Certified Nursing Assistant slap a resident’s face and then punch the resident in the head, while other residents were present, in the facility’s dining area. A plan of correction undertaken by the facility included the removal from duty of the CNA in question.

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Chapin Home for the Aging received 17 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 Jamaica 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 protect residents from abuse and neglect. Under Section 483.12 of the Federal Code, nursing homes must ensure their residents’ “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A June 2019 citation found that Chapin Home for the Aging failed to comply with this section in an instance in which one resident was “observed in his room with his wheelchair leg rest in his hand, raised above” another resident, who was observed in bed “with multiple lacerations and… covered with blood.” The latter resident had lacerations on his scalp and his ear, as well as “excoriations” on his left shoulder and left upper arm. The resident was transferred to the local hospital, where he received 20 medical staples. The citation found that this deficiency on the nursing home’s part resulted in “actual harm.”

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Ozanam Hall of Queens 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 facility was also the subject of a 2018 fine of $2,000 in connection to unspecified findings in a January 2018 survey. The Bayside 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 employ adequate measures to prevent misconduct after a resident alleged abuse by a staffer. Section 483.12 of the Federal Code states that while nursing home facilities investigate allegations of abuse, they must prevent further potential abuse. A January 2018 citation found that Ozanam Hall of Queens failed to do so after a resident made an abuse allegation against a Licensed Practical Nurse. The citation specifically found that the nursing home did not remove the nurse in question from providing care to the resident after the resident reported to a family member that “the staff member roused her from her sleep by grabbing her in the abdominal area without warning.” In response to the “intense pain” she felt from this, the resident stated, she “tried to ward off” the staffer’s hands, and the staffer “slapped her face repeatedly with a pillow and pinched her left upper arm.” In an interview, the facility’s Director of Nursing told an inspector that the facility’s Registered Nurse supervisor “felt she was protecting the resident by not allowing the LPN to enter the resident’s room unsupervised,” and was not aware she could send the Licensed Practical Nurse home. The LPN in question ultimately resigned.

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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 NOT 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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Salem Hills Rehabilitation and Nursing Center received 14 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 Purdys 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 ensure residents’ right to freedom from abuse. Under Section 483.12 of the Federal Code, nursing home facilities must uphold residents’ right to freedom “from abuse, neglect, misappropriation of resident property, and exploitation.” A March 2019 citation found that the nursing home did not ensure this right for one of three residents. An inspector specifically found that a Certified Nursing Assistant, in response to a resident slapping her face, “grabbed and held the resident’s left wrist while continuing to hold the right wrist firmly.” A plan of correction undertaken by the facility included, in part, educating CNAs so they “understand that holding on to another person’s hands or wrist as a knee jerk… action” is not appropriate, and that they should instead distance themselves from residents and seek assistance.

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Beth Abraham Center for Rehabilitation and Nursing received 30 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. The Bronx nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not properly ensure the prevention and control of infection. Under Section 483.80 of the Federal Code, nursing home facilities “must 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.” During a May 2019 inspection, a surveyor observed a Licensed Practical Nurse “performing blood pressure monitoring for 3 residents without cleaning the blood pressure cuff between residents”; another LPN administering eye drop medication without maintaining “proper hand hygiene”; and a third LPN failing to maintain proper hand hygiene while completing a wound care observation.

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