Articles Posted in Pressure Sores

Berkshire Nursing & Rehabilitation Center received 26 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 27, 2020. The West Babylon 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 implement adequate measures to protect its residents from sexual abuse. Under Section 483.12 of the Federal Code, nursing homes have a right “to be free from abuse.” A September 2019 citation found that Berkshire Nursing & Rehabilitation Center did not ensure one resident was free from sexual abuse. The citation states specifically that a “cognitively intact resident… inappropriately touched” a resident with “severely impaired cognition,” and that the nursing home did not launch an investigation “until 2 days after the incident.”  A plan of correction undertaken by the facility included the suspension and re-education of the Nursing Supervisor found to be responsible “for failure to communicate.”

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Good Samaritan Nursing and Rehabilitation Care Center received 21 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 28, 2020. The Sayville 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 (bedsore) care. Section 483.25 of the Federal Code requires nursing homes to ensure that a resident with pressure ulcers receives “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” A March 2018 citation found that Good Samaritan Nursing and Rehabilitation Care Center did not ensure such for one resident. The citation states specificaly that the resident developed a deep tissue injury on their right heel while in the facility, but that “multiple observations were made of the heel not being offloaded (to prevent contact with any surface) per physician’s orders.” In an interview, the facility’s Director of Nursing Services stated that the facility should have provided the resident with “better coordinated” care and that the resident’s “care plan should have been updated” with more specific interventions.

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Bellhaven Center for Rehabilitation and Nursing Care received 23 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 27, 2020. The Brookhaven 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 pressure ulcer (bedsore) care. Section 483.25 of the Federal Code requires nursing homes to ensure that residents who enter without pressure sores do not develop them “unless the individual’s clinical condition demonstrates that they were unavoidable.” A July 2016 citation found that Bellhaven Center for Rehabilitation and Nursing Care did not ensure effective care for a resident at risk of developing a pressure ulcer so as to prevent them from developing a pressure ulcer. The citation states specifically that the resident’s medical records “lacked an individualized plan of care specific to the resident,” and that the resident developed a Nosocomial Stage III pressure ulcer. According to the citation, records revealed that there was “no documented evidence that the resident was turned and position” to prevent the development of ulcers, and a facility staffer stated that “there is no documented evidence that ski n checks were completed.” The citation states that this deficiency resulted in the “potential to cause more than minimal harm.”

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The Grand Rehabilitation and Nursing at Great Neck received 45 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 20, 2020. The Great Neck 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 were free from abuse. Section 483.12 of the Federal Code requires nursing homes to ensure residents’ right to freedom from abuse. A July 2018 citation found that The Grand Rehabilitation and Nursing at Great Neck did not ensure such for one resident. The citation states specifically that a Certified Nursing Aide “spit on a severely cognitively impaired resident… when the resident was exhibiting verbal and physically abusive behavior.” In an interview, the CNA in question said her action was a “reflex action to spit back when the resident had spit had her.” In another interview, the facility’s Director of Nursing said that “the resident’s dignity was violated and the CNA’s behavior was unacceptable.” A plan of correction undertaken by the facility included disciplinary action for several CNAs.

2. The nursing home did not provide adequate treatment and care for pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents receive necessary treatment and services to promote the healing of existing pressure ulcers. A June 2018 citation found that The Grand Rehabilitation and Nursing at Great Neck did not provide such for one resident.

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White Oaks Rehabilitation and Nursing Center received 22 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 21, 2020. The Woodbury 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 implement measures to adequately treat and care for residents’ bedsores / pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to provide residents with necessary treatment and services to promote the healing of pressure ulcers, prevent infection of pressure ulcers, and prevent the development of new ulcers. A February 2017 citation found that White Oaks Rehabilitation and Nursing Center did not ensure such for one resident. The citation states specifically that the physician’s wound care treatment orders for a resident’s Stage IV sacral pressure ulcer “were not revised to address the depth of the wound.” In an interview, the wound care physician stated that the wound’s measurements change with the position of the resident, that the wound was stable, and that he did not expect it to close, so the goal of its treatment was to prevent infection. A plan of correction undertaken by the facility included the evaluation of the resident and clarification of the treatment.

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Westchester Center for Rehabilitation and Nursing received 40 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. That figure is eight greater than the statewide average of 32. The Mount Vernon 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 meet quality of care standards. Section 483.25 of the Federal Code states that nursing homes must ensure that residents “receive treatment and care in accordance with professional standards of practice” and based on comprehensive assessments of each individual. According to a July 17, 2019 inspection, the nursing home did not ensure proper treatment and care for three residents. An inspector found that one resident did not receive “timely treatment and care for complaints of pain” resulting from their fall from a lift; another did not receive timely treatment and care for a bedsore/pressure ulcer on their left heel; and a third was not provided prompt medication, per a physician’s orders, for their “critically elevated potassium levels.” The citation describes these failures as resulting in the “potential to cause more than minimal harm” to residents.

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Sapphire Nursing and Rehab at Goshen received 49 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The Goshen nursing home’s citations resulted from a total of eight surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not properly implement procedures to prevent residents from eloping. Section 483.25 of the Federal Code requires nursing home facilities to provide residents with “adequate supervision and assistance devices to prevent accidents,” including unsafe wandering off the facility’s premises. A June 2019 citation found that Sapphire Nursing and Rehab at Goshen did not ensure one resident was adequately supervised. The citation states that the resident had been assessed at low risk for elopement, but that the facility did not reassess the resident’s supervisory needs after the resident “behavior changes potentially related to increased risk for elopement.” The resident, according to the citation, “exited the building undetected, passing thorough a supervised common room and a supervised lobby, when the assigned staff were distracted by residents that required immediate attention in each of those areas.” The citation goes on to state that the resident was discovered by staff about 20 minutes afterward, then escorted back into the facility. This deficiency, according to the citation, had the “potential to cause more than minimal harm.”

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Grandell Rehabilitation and Nursing Center received 22 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 5, 2020. The facility has also been the subject of a 2018 fine of $12,000 in connection to findings during a 2018 inspection that it violated unspecified health code provisions; a 2016 fine of $16,000 in connection to findings during a 2013 inspection that it violated health code provisions regarding quality of care, administration, and quality assessment and assurance; a 2011 fine of $34,000 in connection to findings that it violated health code provisions regarding medically related social services, accident hazards, resident well-being, administration, and hydration; and a 2010 fine of $2,000 in connection to findings that it violated health code provisions regarding quality of care and nutrition. The Long Beach 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 ensure residents were protected from abuse. Section 483.12 of the Federal Code requires nursing homes to ensure residents’ right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A May 2018 citation found that Grandell Rehabilitation and Nursing Center did not ensure this right for one resident. The citation states specifically that one of the facility’s Recreation Aides “intentionally threw water” at a resident with a redacted diagnosis. The citation states that the RA admitted to throwing water at the resident. A plan of correction undertaken by the facility included the termination of the staff member in question.

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Beach Terrace Care Center received 33 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The Long Beach 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 take adequate measures to care for residents’ bedsores/pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing home facilities must ensure residents receive the necessary care and services to promote the healing of pressure ulcers and bedsores. A May 2019 citation found that Beach Terrace Care Center did not comply with this section. An inspector found specifically that the nursing home “did not perform a timely assessment when a resident’s skin condition changed.” The resident in question had an open blister on their left heel, however, the facility had no documented evidence that this blister was assessed until two days after it was identified. According to this citation, although a Skin Assessment Sheet was filled out to inform the facility’s Wound Care Nurse, no note was written in the resident’s chart at the time it was identified. The citation states that this deficiency had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the education of facility nursing staff on new procedures for documenting skin impairments.

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Highfield Gardens Care Center of Great Neck received 32 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 5, 2020. The Great Neck 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. Section 483.25 of the Federal Code requires nursing homes to provide treatment and services consistent with professional practices to promote the healing of pressure ulcers, heal infection, and prevent new ulcers from developing. A January 2019 citation found that Highfield Gardens Care Center of Great Neck did not ensure such for one resident with a Stage IV sacral pressure ulcer. The citation specifically states that a Licensed Practical Nurse “did not provide treatment consistent with current standards of practice in the maintenance of infection control.” The citation goes on to state that the LPN dressed the resident’s wound and went to wash his hands, at which point the dressing fell off the wound and onto the resident’s briefs. The LPN then put the dressing back on the wound, according to the citation, and when asked by an inspector if the dressing “that he picked up was clean” was unable to answer. In an interview, a Registered Nurse stated that the “dressing that fell on the resident’s brief was not clean and the whole treatment had to be re-done.”

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