Pressure Sores

April 8, 2021

Wesley Gardens Corporation Fined $16,000, Cited for Medication Errors

by Law Offices of Thomas L. Gallivan, PLLC

Wesley Gardens Corporation received 75 citations for violations of public health laws between 2017 and 2021, according to New York State Department of Health records accessed on April 1, 2021. The facility has also received three fines since 2016, totaling $16,000, over findings of health code violations. The Rochester nursing home’s citations resulted from a total of six inspections by state surveyors. The deficiencies they describe include the following:

The nursing home in upstate New York has also received $16,000 in fines since 2016.

1. The nursing home did not adequately prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes must maintain medication error rates below five percent. An August 2019 citation found that Wesley Gardens Corporation failed to ensure such. The citation states specifically that while a resident’s physicians orders stated that their medications were to be administered at 9am, they were observed being administered at 11:10am. In an interview, the Licensed Practical Nurse who administered the medications stated that they were administered late because there was “only one nurse passing medications on the unit,” and that four other residents also received late medication administration. A plan of correction undertaken by the facility included the counseling of the LPN.

April 7, 2021

Creekview Nursing and Rehab Center: $62,000 in Fines, Pressure Ulcer Citation

by Law Offices of Thomas L. Gallivan, PLLC

Creekview Nursing and Rehab Center received 119 citations for violations of public health laws between 2017 and 2021, according to New York State Department of Health records accessed on April 1, 2021. The facility has also received seven fines since 2013, totaling $62,000, over findings of health code violations. The Rochester nursing home’s citations resulted from a total of 13 inspections by state surveyors. The deficiencies they describe include the following:

In addition to infection control lapses, the New York nursing home was also cited for medication errors.

1. The nursing home did not provide an adequate level of care for pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection. An October 2020 citation found that Creekview Nursing and Rehab Center failed to ensure such. The citation states specifically that one resident’s pressure ulcer and skin “were not properly cleaned,” that “the correct dressing was not applied,” and that “the resident was not repositioned as care planned.” A plan of correction undertaken by the facility included the counseling of the Licensed Practical Nurse who completed the care, as well as Certified Nursing Assistants who cared for the resident.

April 6, 2021

The Grand Rehabilitation and Nursing at Mohawk: Pressure Ulcer Citation, $22,000 in Fines

by Law Offices of Thomas L. Gallivan, PLLC

The Grand Rehabilitation and Nursing at Mohawk received 44 citations for violations of public health laws between 2017 and 2021, according to New York State Department of Health records accessed on April 1, 2021. The facility has also received three fines since 2019, totaling $22,000, over findings of health code violations. The Ilion nursing home’s citations resulted from a total of 10 inspections by state surveyors. The deficiencies they describe include the following:

The nursing home in New York was also cited for medication errors.

1. The nursing home did not employ adequate measures to control infection. Section 483.80 of the Federal Code stipulates that nursing homes must help prevent the transmission of communicable diseases and infections by creating and upholding an infection control program. A December 2020 citation found that The Grand Rehabilitation and Nursing at Mohawk failed to ensure such. The citation states specifically that two Certified Nursing Aides “tested positive for COVID-19 and returned to work” before completing a 14-day quarantine and receiving negative PCR tests. Guidance at the time held that nursing home employees who test positive and remain asymptomatic were not eligible to return to work for 14 days from their positive result, while symptomatic employees were required to wait 14 days plus 3 days since the resolution of fever. The citation states that this deficiency had the “potential to cause more than minimal harm.”

March 24, 2021

Salamanca Rehabilitation & Nursing Center

by Law Offices of Thomas L. Gallivan, PLLC

The New York nursing home has received citations for medication errors and pressure ulcer care.

Salamanca Rehabilitation & Nursing Center has received received 68 citations for violations of public health code between 2017 and 2021, according to health records accessed on March 19, 2021. The Salamanca 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 ensure that residents were protected from the use of unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing home residents’ drug regimens “must be free from unnecessary drugs.” An August 2019 citation found that Salamanca Rehabilitation & Nursing Center failed to ensure such. The citation states specifically that one resident was kept on an antibiotic regimen “without adequate indications for its use.” In an interview, the facility’s Assistant Director for Nursing said that the underlying symptoms, “a single episode of burning upon urination” and an increase in temperature, did not meet the nursing home’s “criteria for antibiotic use.” A plan of correction undertaken by the facility included a review of its antibiotics policies and procedures.

March 17, 2021

Chestnut Park Rehabilitation and Nursing Center: Pressure Ulcer Citations

by Law Offices of Thomas L. Gallivan, PLLC

The New York nursing home received 38 citations between 2017 and 2021, including for infection control lapses.

Chestnut Park Rehabilitation and Nursing Center has received received 38 citations for violations of public health code between 2017 and 2021, according to health records accessed on March 38, 2021. The Oneonta nursing home’s citations resulted from a total of three surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not adequately protect residents from infectious disease. Under Section 483.80 of the Federal Code, nursing homes must develop and uphold policies and procedures that help prevent the transmission of infection. A June 2019 citation found that Chestnut Park Rehabilitation and Nursing Center failed to ensure such. The citation states specifically that in connection to one resident; the nursing home “the facility did not ensure soiled attends with feces was discarded appropriately”; in connection to a second resident, the nursing home did not uphold infection control standards during a dressing change; and in connection to two other residents, the nursing home did not ensure the proper administration of a test. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

March 15, 2021

New Investigation Uncovers Flaws in Nursing Home Rating Systems

by Law Offices of Thomas L. Gallivan, PLLC

An investigation found that nursing homes with five-star ratings often received citations for abuse and neglect.

A new investigation by the New York Times examines how nursing homes use the star rating system to “mislead the public.” As the article explains, the nursing home star rating system, in which one star is the lowest rating and five star is the highest ratings, has been “a popular way for consumers to educate themselves and for nursing homes to attract new customers.”

However, the report suggests, the system in fact offers “a distorted picture of the quality of care” at nursing homes, with many facilities manipulating the rating system to conceal failings that led to disproportionate nursing home resident deaths during the Covid-19 pandemic. The Times ultimately found that residents “at five-star facilities were roughly as likely to die of the disease as those at one-star homes.” Continue reading

March 8, 2021

Saratoga Center for Rehab and Skilled Nursing Care: Infection, Pressure Ulcer Citations

by Law Offices of Thomas L. Gallivan, PLLC

The New York nursing home has received more than 80 health citations in the last for years.

Saratoga Center for Rehab and Skilled Nursing Care has received 88 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on March 5, 2021, as well as four fines totaling $36,000 since 2014. The Ballston Spa nursing home’s citations resulted from a total of 7 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not implement adequate infection control practices. Under Section 483.80 of the Federal Code, nursing homes must create and uphold an infection prevention and control program that helps to prevent the development and transmission of disease and infection. A November 2019 citation found that Saratoga Center for Rehab and Skilled Nursing Care failed to ensure such. The citation states specifically that the facility did not ensure the annual updating of infection control policies, and further, that the facility did not maintain “standard precautions” during a resident’s dressing change. The citation goes on to describe an instance in which a Graduate Practical Nurse was conducting a dressing change for a resident’s pressure ulcer and did not properly remove their gloves or perform hand hygiene after cleansing the wound and before applying ointment. The citation finally states that in certain shared bathrooms in the facility, residents’ personal items were not labeled. A plan of correction undertaken by the facility included the review of infection prevention policies.

March 1, 2021

Robinson Terrace Rehabilitation and Nursing Center: Pressure Ulcer, Infection Citations

by Law Offices of Thomas L. Gallivan, PLLC

The Stamford, New York nursing home has also received $26,000 in fines.

Robinson Terrace Rehabilitation and Nursing Center suffered 15 confirmed and 7 presumed COVID-19 deaths as of February 28, 2021, according to state records. The facility has also received 46 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on February 12, 2020, as well as three fines totaling $26,000 since 2012. The Stamford 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 provide adequate pressure ulcer care. Section 483.25 of the Federal Code requires that nursing homes provide residents with professional levels of care to prevent pressure ulcers from developing and to promote the healing (and prevent the infection of) existing ulcers. An October 2020 citation found that Robinson Terrace Rehabilitation and Nursing Center failed to ensure such. The citation states specifically that the nursing home did not implement professional standards of practice for infection control after changing the dressing on a resident’s pressure ulcer, and that the resident was not turned and positioned from one side to another every two hours in accordance with their care plan. The citation goes on to describe a dressing change in which a Licensed Practical Nurse did not perform proper hand hygiene or change gloves between the removal of one wound’s dressing and the removal of another, on the same resident. In an interview, the LPN stated that care for these wounds “was regularly performed together, despite the wounds being separate wounds” and having separate physicians’ orders for wound care. A plan of correction undertaken by the facility included the reeducation of the LPN in question.

February 17, 2021

Bridgewater Center for Rehabilitation & Nursing Cited for Pressure Sores, Med Errors

by Law Offices of Thomas L. Gallivan, PLLC

Bridgewater Center for Rehabilitation & Nursing suffered 26 confirmed and 15 presumed COVID-19 deaths as of February 4, 2021, according to state records. The facility has also received 41 citations for violations of public health code between 2017 and 2020, according to New York State Department of Health records accessed on February 12, 2020. The Binghamton 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 implement proper measures to prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes are required to keep residents “free of any significant medication errors.” A June 2017 citation found that Bridgewater Center for Rehabilitation & Nursing failed to ensure such for three residents. In one case, the citation states, a resident’s orders for an antipsychotic medication “were not clarified when a change in dosage was made.” In two other cases, residents who had orders for fingerstick and sliding scale insulin administration during mealtimes were not administered such according to meal times. A plan of correction undertaken by the facility included the in-servicing of nursing staff on medication policies and procedures.

2. The nursing home did not provide adequate treatment and services to prevent and heal pressure ulcers. Section 483.25 stipulates that nursing homes must provide residents with receive care and services to prevent the development of pressure ulcers, and to provide residents with pressure ulcers necessary treatment and services to promote healing and prevent infection. A June 2017 citation found that Bridgewater Center for Rehabilitation & Nursing failed to ensure such. The citation states specifically that a resident who was documented at risk for pressure ulcer development, and who used a pressure-reducing device in their chair and bed, had no documented evidence that they were provided with off-loading boots per their care instructions, and ultimately developed a pressure ulcer on their left heel. In a pair of interviews, a nurse at the facility stated that the resident had refused to wear the boots. A plan of correction undertaken by the facility include the in-servicing of nursing staff on the facility’s pressure ulcer policies and procedures.

January 19, 2021

Our Lady of Peace Nursing Care Residence: Pressure Ulcer Citation

by Law Offices of Thomas L. Gallivan, PLLC

As of January 17, 2021, the New York nursing home had 22 confirmed COVID-19 deaths.

Our Lady of Peace Nursing Care Residence suffered 22 confirmed COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 13 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Lewiston 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 protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to provide residents with sufficient supervision and assistive devices to prevent them from sustaining accidents. A January 2020 citation found that Our Lady of Peace Nursing Care Residence failed to ensure such for one resident. The citation states specifically that the resident was on aspiration precautions and that their care plan provided for “small bites and sips, alternate solids with liquids, encourage to eat slow, supervision assistance with eating.” However, the citation states, the resident was not adequately supervised during a mealtime and “was observed to cough several times.” A plan of correction undertaken by the facility included a review of aspiration precaution procedures and the re-education of nurses involved with the resident’s feeding assistance.