Articles Posted in Pressure Sores

Long Beach Nursing and Rehabilitation Center received 29 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 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 provide adequate treatment and care for residents’ pressure ulcers / bedsores. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents receive “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” The citation states specifically that while a resident’s care plan interventions provided for the offloading of their heels “in bed with pillows and to have a Roho cushion when in the gerichair,” a surveyor observed the resident in his bed with his feet resting on a mattress, and in a gerichair without the Roho cushion. A plan of correction undertaken by the facility included the education of the Certified Nursing Assistant “who failed to follow the resident’s plan of care.”

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Mayfair Care Center received 42 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 6, 2020. The Hempstead 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 adequate measures to protect residents from abuse. Section 483.12 of the Federal Code provides nursing home residents with “the right to be free from abuse.” A July 2018 citation found that Mayfair Care Center did not ensure this right for one resident. The citation states specifically that the resident wandered into the room of another resident “with a history of physically abusive behavior,” who then pushed the first resident to the floor, resulting in a redacted medical condition and transfer to the hospital. The citation notes that this deficiency resulted in the occurrence of “actual harm.”

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Parkview Care and Rehabilitation Center 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 6, 2020. The facility has also been the subject of a 2017 fine of $4,000 in connection to findings that it violated health code provisions regarding quality of life and unnecessary drugs; and a 2016 fine of $12,000 in connection to findings in a 2014 inspection that it violated health code provisions regarding quality of care and administration. The Massapequa 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 ensure proper treatment and care of pressure ulcers and bedsores. Under Section 483.25 of the Federal Code, nursing homes must provide residents with pressure ulcers “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A September 2016 citation found that Parkview Care and Rehabilitation Center did not provide such for one resident. The citation states specifically that the resident was assessed by a Licensed Practical Nurse for a pressure ulcer acquired while at the facility, and that “there was no documented evidence that the Nurse Practitioner (NP) or other qualified health professional completed an assessment of the pressure ulcer.” In an interview, the facility’s nurse practitioner stated that they were not aware why there was no evidence of the ulcer’s assessment by a “qualified health professional,” and that the facility’s wound care physician was not available to provide any comment. A plan of correction undertaken by the facility included the nurse practitioner’s assessment of the pressure ulcer. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Cold Spring Hills Center for Nursing and Rehabilitation received 24 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 27, 2020. The facility has also been the subject of a 2016 fine of $12,000 in connection to findings during a 2015 inspection that it violated health code provisions regarding quality of care and staff mistreatment of residents; and a second 2016 fine of $10,000 in connection to findings during a 2015 inspection that it violated health code provisions regarding accidents. The Woodbury nursing home’s citations resulted from a total of 11 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate pressure ulcer treatment and care. Section 483.25 of the Federal Code requires nursing homes to ensure residents receive necessary treatment and services to promote the healing of pressure ulcers and the prevention of new ulcers from developing. A September 2019 citation found that Cold Spring Hills Center for Nursing and Rehabilitation did not ensure such for one resident. The citation states specifically that a pressure ulcer identified by the resident on September 20, 2018 was not assessed by a Registered Nurse until September 23, 2018. The citation states further that the RN in question “initiated treatment without a physician’s orders,” and that the lack of a pressure ulcer assessment resulted in “actual harm” to the resident.

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Villagecare Rehabilitation and Nursing Center received 12 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 31, 2020. The Manhattan 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 prevent and care for pressure ulcers and bedsores. Section 483.25(c) of the Federal Code states that nursing homes must ensure residents receive a quality of care that prevents those admitted without pressure sores from developing such unless their condition renders it unavoidable; and that residents who have pressure sores receive necessary and proper care.

A November 2016 citation found that Villagecare Rehabilitation and Nursing Center neglected to ensure the provision of necessary treatment to a resident with a documented stage 2 pressure ulcer. The citation states specifically that in the resident’s Nursing Skin assessment for October 7, 2016 “The box to be checked indicating the presence of a pressure ulcer was not checked,” and the “skin examination section documented intact skin and the comment section was blank.” It goes on to state that there was an absence of documented evidence any “wound care orders were obtained when the pressure ulcer was identified” on October 6, 2016. In an interview, a Certified Care Associated stated that when she first cared for the resident, she informed a nurse that the resident had experienced skin breakdown; the Nurse Practitioner stated in an interview, however, that she documented the resident’s skin as dry and intact, and “may have missed identification of the sacral pressure ulcer.” A plan of correction undertaken by the facility included the in-servicing of nursing and medical staff.

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Central Island Healthcare received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 27, 2020. The Plainview 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 specifies that nursing home residents are entitled “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” An April 2018 citation found that Central Island Healthcare did not ensure this right for one resident. The citation found specifically that a Certified Nursing Assistant at the facility “forcibly placed” the resident in their bed “and changed the resident’s clothes against the wishes repeatedly expressed by the resident to remain dressed and out of bed.” A plan of correction undertaken by the facility included the suspension, investigation, and termination of the CNA in question.

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Glen Cove Center for Nursing and 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 February 27, 2020. The facility has also been the subject of a 2016 fine of $12,000 in connection to findings during a 2015 inspection that it violated health code provisions regarding bedsores/pressure soresband notifications; and a second 2016 fine of $10,000 in connection to findings during a 2014 inspection that it violated health code provisions regarding quality of care. The Glen Cove 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 keep residents free from unnecessary medications. Under Section 483.25 of the Federal Code, nursing homes must ensure that “each resident’s drug regimen [is] free from unnecessary drugs.” An April 2016 citation found that Glen Cove Center for Nursing and Rehabilitation did not ensure one resident was protected from unnecessary medications. The citation states specifically that the resident was given an antipsychotic drug “without documented evidence of the specific clinical symptoms, resident-specific non-pharmacological interventions attempted or monitoring of the effectiveness of the medication.” A plan of correction undertaken by the facility included the in-servicing of the facility’s licensed nurses “on the need to document specific clinical symptoms & behavioral interventions” before administering antipsychotic medications.

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Glengariff Rehabilitation and Healthcare Center received 38 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 27, 2020. The facility has also been the subject of a 2015 fine of $12,000 in connection to findings during a 2013 inspection that it violated health code provisions regarding quality of care, administration, and quality assessment and assurance. The Glen Cove 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 ensure the adequate implementation of infection prevention and control measures. 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 September 2018 citation found that Glengariff Rehabilitation and Healthcare Center did not ensure the implementation of such for two residents observed with pressure ulcers, and one reviewed for a purified protein derivative vaccination. The citation states specifically that a Licensed Practical Nurse wore the same gloves while cleansing wounds on two different pressure ulcer sites, and that a resident with two PPD implants had no “documented evidence as to when [they] were read.” The citation states that these deficiencies had the “potential to cause more than minimal harm.”

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Northern Metropolitan Residential Health Care Facility received 17 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 Monsey 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 implement proper steps to care for pressure ulcers and bedsores. Section 483.25 of the Federal Code stipulates, among other things, that nursing home facilities must provide residents with the necessary treatment and care to promote the healing of pressure sores. A March 2017 citation found that Northern Metropolitan Residential Health Care Facility did not ensure the provision of necessary care and treatment to a resident with a sacral pressure ulcer. The citation states specifically that the nursing home “did not ensure that a protein supplement was administered to the resident as ordered by a Nurse Practitioner to promote wound healing.” In an interview, one of the facility’s Registered Nurses stated that the supplement “was not correctly picked up” and as such was not given to the resident. The citation describes this deficiency as having the “potential to cause more than minimal harm.”

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Nyack Ridge Rehabilitation and Nursing 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 February 13, 2020. The Valley Cottage 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 pressure ulcers and bedsores. Section 483.25 of the Federal Code requires nursing homes to ensure patients receive necessary care and services to prevent the treatment of pressure ulcers. A June 2018 citation found that Nyack Ridge Rehabilitation and Nursing Center did not provide necessary care and treatment to one resident. The citation states specifically that “redness and scab formation developed on the resident’s left cheek from a nasal cannula oxygen tubing applied on the resident’s face.” In an interview, the facility’s Registered Nurse manager stated that “the reddened area on the resident’s cheek should be addressed in the care plan,” and the citation notes that interventions were subsequently added to the care plan.

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