Articles Posted in Pressure Sores

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Waters Edge Rehab & Nursing Center at Port Jefferson received a total of 22 citations between 2018 and 2022 as a direct result of six inspections by state surveyors.

Waters Edge Rehab & Nursing Center at Port Jefferson received 22 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on May 13, 2022. The Port Jefferson nursing home’s citations resulted from a total of six inspections by state surveyors. The deficiencies they describe include the following:

1. The citation did not effectively care for residents’ pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents receive a level of care adequate to prevent the avoidable development of pressure ulcers, and that residents with pressure ulcers receive care and services to promote both their healing and the development of additional ulcers. A February 2022 citation found that Waters Edge Rehab & Nursing Center at Port Jefferson failed to ensure such. The citation specifically describes a resident with a pressure ulcer on their right heel for whom “facility staff did not consistently conduct weekly assessments.” In fact, the citation states, the resident was not referred to the facility’s wound care team “until 18 days after the PU [pressure ulcer] was first identified.” In an interview, the facility’s Director of Nursing Services said that “should have been seen by the wound care nurse as soon as possible on the day of the PU identification.” A plan of correction undertaken by the facility included the counseling and education of two certified nursing assistants.

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A recent report by the Long Term Care Community Coalition shares that deficiencies in nursing homes across the United States are not being classified as harmful to the residents, which appears to be false and potentially dangerous for many nursing home residents.

A recent report by the Long Term Care Community Coalition raises important questions about “no harm” deficiencies in nursing homes across the United States.  “No Harm” deficiencies are health violations cited by official surveyors that are classified as causing no harm to residents. As the LTCCC argues in its Elder Justice newsletter, “no harm” citations often appear on their face to indeed be harmful, and that because they rarely result in financial penalties, this potentially erroneous classification leaves nursing homes without any incentive to correct systemic deficiencies. The LTCCC report describes several recent “no harm citations,” asking the reader whether the classification appears honest and accurate.  Continue reading

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Long Beach Nursing Home and Rehabilitation Center has received 26 citations for being in violation of public health code since 2018 after a total of 6 surveys by state inspectors.

Long Beach Nursing and Rehabilitation Center received 26 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 22, 2022. The Long Beach 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 take proper steps to protect residents from accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments are as free as possible of accident hazards. A July 2021 citation found that Long Beach Nursing and Rehabilitation Center failed to ensure such. The citation specifically describes an instance in which a resident “was observed with four razors within their room,” and another instance in which “oral medications were left unattended” by a nurse on a resident’s over-bed table. A plan of correction undertaken by the facility included the re-education and in-servicing of the staffers in question.

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Glen Arden received 15 citations for being in violation of public health code between 2018 and 2022 after a total of 3 surveys by state inspectors found multiple deficiencies within the nursing home.

Glen Arden received 15 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Goshen 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. Under Section 483.25 of the Federal Code, nursing homes must provide residents with a level of care necessary to promote the healing of pressure ulcers. A September 2020 citation found that Glen Arden failed to ensure such. The citation specifically states that a nurse practitioner’s recommendations to promote the healing of a “new deep tissue injury” and scab on a resident’s toe “were not implemented timely.” In an interview, the nurse practitioner said that this lapse could potentially result in an infection. A plan of correction undertaken by the facility included the updating of the resident’s care plan and treatment of the resident’s wound. 

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Northern Riverview Health Care Center has received 38 citations for being in violation of  public health code between 2018 and 2022 after a total of 4 surveys by state inspectors found multiple deficiencies within the Haverstraw nursing home.

Northern Riverview Health Care Center received 38 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Haverstraw 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 employ adequate accident-prevention measures. Under Section 483.25 of the Federal Code, nursing homes must provide residents with adequate supervision and assistance devices to prevent accidents, including elopement. A December 2021 citation found that Northern Riverview Health Care Center failed to ensure such. The citation specifically describes a resident with “severe cognitive impairment,” known to be “a high risk for elopement,” who exited the nursing home through its front door “unnoticed by facility staff.” The individual was later found outside the facility by local police officers. In an interview, the facility’s receptionist said they were distracted at the time of the incident because “the front desk was very busy with employees and visitors coming in and out of the facility, including discharging a resident to home.” A plan of correction undertaken by the facility included the educational counseling of the receptionist.

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Bushwick Center for Rehabilitation and Health Care in Brooklyn, NY has received a total of 13 citations for being in violation of public health code since 2018 after state inspectors found multiple deficiencies within the facility.

Bushwick Center for Rehabilitation and Health Care has received 13 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on March 19, 2022. 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 provided inadequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing homes must ensure residents receive professional levels of care to prevent the development of pressure ulcers where clinically avoidable. A May 2021 citation found that Bushwick Center for Rehabilitation and Health Care failed to ensure such. The citation specifically describes a resident identified as at high risk for the development ulcers, who “was not provided with preventive skin care to prevent skin breakdown and pressure ulcers upon admission.” The citation goes on to state that the resident consequently developed a deep tissue injury and two moisture-associated wounds. In an interview, the facility’s wound care nurse said “There should have been interventions in place to prevent skin breakdowns,” and further that “Anyone who is at risk for skin breakdown should have interventions in place to prevent skin breakdown upon admission.” A plan of correction undertaken by the facility included the education of nursing staff on pressure ulcer prevention.

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King David Center for Nursing and Rehabilitation has received 23 citations for being in violation of public health code since 2018 after state inspectors found multiple deficiencies within the Brooklyn nursing home.

King David Center for Nursing and Rehabilitation has received 23 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on March 19, 2022. 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 provide adequate pressure ulcer care. Section 483.35 of the Federal Code stipulates that nursing homes must ensure residents receive a level of care consistent with professional standards to prevent the development of pressure ulcers unless clinically unavoidable. A November 2021 citation found that King David Center for Nursing and Rehabilitation failed to ensure such. The citation specifically describes two residents identified as at risk for pressure ulcers who “were not provided with preventive skin care to prevent skin breakdown and pressure ulcers upon admission.” The citation goes on to describe one resident with a pressure ulcer, whose Certified Nursing Assistant Accountability Sheet “did not reflect any evidence that the resident was turned and positioned every two hours,” and for whom there was no documentation that other interventions were implemented. A plan of correction undertaken by the facility included the in-servicing of all relevant staff. 

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Briarcliff Manor Center for Rehabilitation and Nursing has received a total of 27 citations for being in violation of public health code since 2018 for failing to properly care for pressure ulcers, failing to prevent infection, and for dismissing the rights of the residents.

Briarcliff Manor Center for Rehabilitation and Nursing has received 27 citations for violations of public health code between 2018 and 2021, according to New York State Department of Health records accessed on February 11, 2022. The Briarcliff Manor 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 provide adequate pressure ulcer care. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents appropriate care to promote the healing of pressure ulcers. A November 2020 citation found that Briarcliff Manor failed to ensure such. The citation states specifically that a resident’s feet were not offloaded at all times per a physician’s order, and that another resident’s heel booties were not applied in accordance with a physician’s order. In an interview, a Certified Nursing Assistant said she was unaware the latter resident should have been wearing heel booties; in another interview, a nurse confirmed that the order for the resident to wear heel booties had not properly been registered into the resident’s record, and “may have been entered into the system incorrectly.” A plan of correction undertaken by the facilities included the in-servicing of relevant staff.

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Rosewood Rehabilitation and Nursing Center has received a total of 77 citations for being in violation of public health code since 2018 and may even be placed on a Special Focus Facilities list for failing to properly care for its residents.

Rosewood Rehabilitation and Nursing Center has received 77 citations for violations of public health code between 2018 and 2021, according to New York State Department of Health records accessed on January 29, 2022. The facility has also been named a candidate for the Center for Medicare and Medicaid Services’ list of Special Focus Facilities, nursing homes with a history of quality issues. The Rensselaer nursing home’s citations resulted from a total of 12 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not implement adequate measures to prevent infections. Section 483.80 of the Federal Code stipulates that nursing homes must establish and maintain an effective infection prevention and control program. A December 2021 citation found that Rosewood Rehabilitation and Nursing Center failed to ensure such. The citation states specifically that the nursing home “did not ensure facility staff cleansed scissors after using them to remove a contaminated dressing and prior to using the scissors to cut a wound packing, and did not place a contaminated item in a multi-resident use treatment cart.” It goes on to describe an instance in which a staff member did not undertake hand hygiene procedures between taking off soiled gloves and putting on clean gloves. In an interview, the facility’s Director of Nursing said that “hand hygiene should be performed before and after providing resident care, after each glove removal and between each area when providing wound care.” A plan of correction undertaken by the facility included the re-education of relevant staff. 

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Fordham Nursing Home and Rehabilitation Center has received a total of 15 citations since 2017 for violating public health code on more than one occasion.

Fordham Nursing and Rehabilitation Center received 15 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 14, 2022. The Bronx nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing homes must ensure residents receive necessary care and services to prevent the development of pressure ulcers. A December 2019 citation found that Fordham Nursing and Rehabilitation Center failed to ensure such. The citation specifically describes a resident who was “observed on multiple occasions without heel booties or diabetic shoes,” devices meant to prevent pressure ulcers, as ordered by the physician. In an interview, a Certified Nursing Assistant said that “it is not a regular occurrence for the resident to be without her heel booties.” In another interview, a Registered Nurse said she was unable to find the resident’s diabetic shoes in the resident’s room. A plan of correction undertaken by the facility included the application of the shoes to the resident and the location of the heel booties, as well as a notation on the resident’s care plan that “the blue heel booties were to be worn at all times when the resident is in bed and diabetic shoes are to be worn when the resident is out of bed.”

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