Articles Posted in Pressure Sores

Rockville Skilled Nursing & Rehabilitation Center received 18 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 14, 2020. The Rockville Centre 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 adequately treat and care for residents’ pressure ulcers and bedsores.  Section 483.25 of the Federal Code requires nursing homes ensure that residents with pressure ulcers receive “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure one resident with pressure ulcers received such. The citation states specifically that although a nurse noted the resident’s bilateral heels had “discoloration and were soft and tender,” the Registered Nurse’s full assessment of that resident’s heels “was not relayed to the physician in a timely manner, resulting in a delay in treatment.” In an interview, the Registered Nurse Supervisor stated that she had assessed the resident and documented her findings, but “forgot to write a progress note,” and then passed the findings to a wound nurse. In an interview, that nurse stated that she told the RN supervisor that a note had to be put in the resident’s medical record, and further that told the facility’s Assistant Director of Nursing Services about the resident’s condition, who “wanted to wait for the progress note to be written.”

2. The nursing home did not take adequate measures to prevent residents from being administered unnecessary psychotropic drugs. Section 483.45 of the Federal Code requires nursing homes to ensure that “Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure residents taking medication for a redacted condition received gradual dose reductions, “unless clinically contraindicated, in an effort to discontinue these drugs.” The citation specifically describes one resident who was prescribed an antipsychotic medication, Quetiapine, and whose psychiatrist and pharmacy consultant “both recommended a tapering of the medication.” However, according to the citation, “there was no documented evidence that the physician took any action” to implement this recommendation. A plan of correction undertaken by the facility included the implementation of the drug’s dose reduction.

Sands Point Center for Health and Rehabilitation received 35 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 15, 2020. The Port Washington 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 and treatment. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with pressure ulcers “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A July 2018 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for one resident. The citation states specifically that “there was no documented evidence that a skin condition to the sacrum was assessed or received treatment until five days after the resident was admitted to the facility.” In an interview, the facility’s wound nurse stated that she had not seen the resident until several days after a note was left for her about the wound, and that “the wound should have been treated sooner.” The facility’s Medical Doctor stated further, in an interview, that “the doctor should have been called over the weekend and a treatment initiated.”

2. The nursing home did not take adequate measures to protect residents from the use of unnecessary drugs. Under Section 483.45 of the Federal Code, nursing homes are required to keep “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for three residents. The citation goes on to state specifically that one resident was administered an antipsychotic medication despite an absence of any “documented justification or attempts at non-pharmacological intervention”; that another resident was administered an antipsychotic medication without an appropriate diagnosis and that a third resident was administered multiple drugs, including an antipsychotic, without an appropriate psychiatric diagnosis. The citation states that this deficiency had the “potential to cause more than minimal harm” to residents.

The Five Towns Premier Rehabilitation & Nursing Center received 28 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 17, 2020. The facility has also received five fines between 2013 and 2019, totaling $58,000, for findings that it violated health code provisions concerning accidents, administration, quality of care, and more. The Woodmere 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 provide adequate treatment and care for residents with pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to provide residents without pressure ulcers necessary care to prevent pressure ulcers from developing unless unavoidable, and residents with pressure ulcers the necessary care to promote healing, prevent infection, and prevent the development of new ulcers. An October 2018 citation found that The Five Towns Premier Rehabilitation & Nursing Center did not provide such for two residents. The citation states specifically that a resident who was at moderate risk of developing a pressure ulcer developed two ulcers after admission, and that their wounds “were not promptly identified, reported, assessed and monitored, and treatments were not implemented as per the physician’s orders.” As for the other resident, the citation states that they had a stage 4 pressure ulcer, but a physician’s recommendation that they be hospitalized for debridement of the wound was not addressed, resulting in harm to the resident.

2. The nursing home did not ensure residents were protected from significant medication errors. Section 483.45 of the Federal Code requires nursing homes to ensure residents’ are kept “free of any significant medication errors.” An October 2018 citation found that The Five Towns Premier Rehabilitation & Nursing Center did not ensure such for one resident. The citation found specifically that a Licensed Practical Nurse administered an ear medication to the resident’s eye. Later, the resident “complained of mild irritation to the eyes” and “was noted with redness to the eyes.” In an interview, the LPN said that while administering the drug she was “distracted because she was conversing with the [resident’s] family member.” A plan of correction undertaken by the facility included the educational counseling of the LPN.

Our Lady of Consolation Nursing and Rehabilitative Care Center received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 9, 2020. The West Islip 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 prevent sexual abuse. Section 483.12 of the Federal Code provide nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A December 2017 citation found that Our Lady of Consolation Nursing and Rehabilitative Care Center did not ensure that right for one resident. The citation states specifically that a Certified Nursing Assistant witnessed a resident “expose his penis and place” a female resident’s “right hand on his exposed genitalia.” The citation goes on to state that the resident’s records, although they documented past inappropriate behavior, “lacked addressing specific behaviors” for the resident “such as keeping [him] arm’s length away from the female residents.” A plan of correction undertaken by the facility included the resident’s discharge.

2. The nursing home did not adequately treat and care for pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing home facilities “ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A November 2016 citation found that Our Lady of Consolation Nursing and Rehabilitative Care Center did not ensure a resident’s pressure ulcer was assessed after it was identified, nor that a weekly measurement was initiated to monitor its progress. The citation states further that the nursing home did not ensure the review of a physician’s treatment order so as to guarantee the appropriate treatment of the pressure ulcer. In an interview, the facility’s Director of Nursing Services stated that the facility’s Registered Nurse Unit Manager should have initiated the Wound Assessment and Progress Record, and further that the physician who had cared for the resident had “since resigned.”

Susquehanna Nursing & Rehabilitation Center suffered 15 deaths from Covid-19 as of June 8, 2020, per state records. The nursing home also received 29 citations for violations of public health code between 2016 and 2020, including two concerning findings of infection prevention code violations, according to health records accessed on June 9, 2020. The Johnson City nursing home’s citations resulted from a total of five surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not adequately implement and infection prevention and control program. Section 483.80 of the Federal Code stipulates that nursing homes must establish and maintain an IPCP that is “designed to provide a safe, sanitary and comfortable environment” and to help stave off the development of communicable infections and diseases. A July 2018 citation found that Susquehanna Nursing & Rehabilitation Center did not ensure such for two residents. The citation states specifically that there were no signs on the residents’ doors indicating that they were on contact precautions, and that staff were observed providing care to the rooms in question without wearing appropriate personal protective equipment or conducting proper hand hygiene. In an interview, a Registered Nurse Unit Manager stated that she did not know one of the residents had no sign on his door, and that anyone entering the room was expected to don PPE. A plan of correction undertaken by the facility included the re-education of direct care staff.

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Vestal Park Rehabilitation and Nursing Center suffered 7 deaths from Covid-19 as of June 8, 2020, per state records. The nursing home also received 38 citations for violations of public health code between 2016 and 2020, two of which concerned infection prevention protocols, according to health records accessed on June 9, 2020. The Vestal nursing home’s citations resulted from a total of four surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not maintain an infection prevention and control program. Section 483.80 of the Federal Code requires nursing homes to establish and maintain an IPCP that helps prevent the transmission of diseases and infections. A March 2018 citation found that Vestal Park did not ensure such. The citation states specifically that a resident was observed with her catheter bag “lying directly on the floor through 4 days of the survey process.” In an interview, a Certified Nursing Assistant said that the catheter bag “was to be covered when out of her room,” and when in the room it was “positioned hanging from the bed and not touching the floor,” as touching the floor posed an infection control risk. One of the facility’s Licensed Practical Nurses stated in another interview that “the resident’s catheter bags were to be covered and not to touch the floor as that was a[n] infection control issue.” A plan of correction undertaken by the facility included a weekly audit of all residents with catheters and the re-education of nursing staff on infection control policies and procedures.

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Quantum Rehabilitation and Nursing received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 9, 2020. The facility has also received two fines: one 2019 fine of $10,000 in connection to findings in a 2019 inspection that it violated unspecified health code provisions; and one 2016 fine of $8,000 in connection to findings in a 2014 inspection that it violated health code provisions regarding investigations, accidents, and administration. The Middle Island 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 treatment. Section 483.25 of the Federal Code requires nursing homes to ensure 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.” An April 2019 citation found that Quantum Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the resident’s “skin integrity deteriorated over a five-day period resulting in open areas, pain and crying,” but that these changes were neither promptly reported to nor assessed by health professionals, and “appropriate treatment was not implemented” until seven days after the changes were initially noted. The citation states that this deficiency resulted in “actual harm.”

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Ross Center for Nursing and Rehabilitation received 31 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 9, 2020. The facility has also received a 2011 fine of $10,000 in connection to findings in a 2010 inspection that it violated health code provisions regarding accidents and supervision. The Brentwood 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 bedsore / pressure ulcer treatment and care. Section 483.25 of the Federal Code requires nursing homes to ensure that residents with pressure ulcers are provided with treatment and services necessary “to promote healing, prevent infection and prevent new ulcers from developing.” A July 2017 citation found that Ross Center for Nursing and Rehabilitation did not ensure such for one resident. The citation states specifically that the nursing home “did not effectively evaluate factors that could be removed or modified to stabilize, reduce, or remove risk factors which contributed to the development and deterioration” of the resident’s pressure ulcer. According to the citation, the resident was given a concave mattress placed atop a pressure relieving mattress. In interviews, facility staff suggested that the concave mattress “impeded staff from properly turning and positioning” the resident, and further that the mattress “did not provide optimum level of pressure reduction for wound healing.” As such, according to the citation, the resident “developed a stage 2 pressure ulcer which then deteriorated to a stage 3.” A plan of correction undertaken by the facility included the educational counseling of its Unit Manager.

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Harris Hill Nursing Facility experienced 26 deaths from Covid-19 as of May 31, 2020, per state records. The nursing home also received 19 citations for violations of public health code between 2016 and 2020, according to health records accessed on June 1, 2020. The Williamsville nursing home’s citations resulted from a total of four surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not provide adequate bedsore / pressure ulcer treatment. Section 483.25 of the Federal Code requires nursing homes to provide residents with treatment to promote the healing and prevent the infection of existing ulcers, and to provide care necessary to prevent the development of new ulcers. An October 2018 citation found that Harris Hill Nursing Facility did not ensure such was provided for one resident. The citation states specifically that the resident was assessed to be “at risk” of developing pressure ulcers, and also had a Stage 2 Pressure ulcer when they were admitted. It goes on to state that a nurse was not timely notified by a Certified Nursing Assistant of new skin breakdown. A plan of correction undertaken by the facility included the re-education of the CNA. Continue reading

San Simeon by the Sound Center for Nursing & Rehabilitation received 25 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 10, 2020. The Greenport 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 provide adequate  bedsores / pressure ulcer care. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents with pressure ulcers receive “necessary treatment and services, consistent with professional standards of practice.” An October 2017 citation found that San Simeon by the Sound Center for Nursing & Rehabilitation did not ensure such for one resident. The citation states specifically that the facility “did not compete thorough assessments nor provide adequate treatment” of a resident assessed upon admission as at risk of pressure ulcers. A plan of correction undertaken by the facility included the review of the charts of all residents with stage 2 or greater pressure wounds.

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