Articles Posted in Pressure Sores

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Campbell Hall Rehabilitation Center has received a total of 77 citations since 2017 for being of violation of public health code and for failing to properly care for their residents.

Campbell Hall Rehabilitation Center received 77 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 7, 2022. The facility was recently placed on the Centers for Medicare and Medicaid Services’ list of “Special Focus Facilities” candidates, meaning it has a record of serious citations. The Campbell Hall nursing home’s citations resulted from a total of 15 inspections by state surveyors. 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 with necessary care and treatment to promote the healing of pressure ulcers. An August 2021 citation found that Campbell Hall Rehabilitation Center failed to ensure such for one resident. The citation states specifically that the resident’s records contained “no consistent documentation… to prove that that interventions and treatments were administered in accordance with the written care plan, and physician’s orders.” In interviews, facility nurses said that they conducted wound treatment but neglected to record it, with one saying that they “sometimes overlook signing treatments” in the resident’s records. A Certified Nursing Assistant said in one interview that she had observed the resident’s wound deteriorating and accordingly reported this to a nurse. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Warren Center for Rehabilitation and Nursing has received over 70 citations for being in violation of public health code since 2017 and has been fined a total of $14,000 since 2011.

Warren Center for Rehabilitation and Nursing has received 73 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 7, 2022. The facility has additionally received three fines totaling $14,000 since 2011, the most recent being a $10,000 fine issued in December 2017. The Queensbury 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 adequately prevent the use of unnecessary medications. Section 483.45 of the Federal Code stipulates that nursing home residents’ drug regimens “must be free from unnecessary drugs.” A September 2021 citation found that Warren Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically that one resident received an opioid pain medication even though their medical record did not include a clinical indication supporting its use, nor documentation to support an increase in dosage. In an interview, one of the facility’s Certified Nursing Assistants said that “they did not provide non-pharmacological interventions for pain management for this resident and the resident was not care planned for specific interventions for the nurse assistants to provide.” A plan of correction undertaken by the  facility included the re-education of licensed nurses on policy regarding medication administration.

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Throgs Neck Rehabilitation and Nursing Center in the Bronx has received 22 citations in the last four years after surveys by state inspectors and has been fined $2,000 for violating health codes.

Throgs Neck Rehabilitation & Nursing Center has received 22 citations for violations of public health code between 2017 and 2021, according to records accessed on December 17, 2021. It also received a $2,000 fine in 2021 over findings it violated health code provisions. The Bronx nursing home facility’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 prevent medication errors. Section 483.45 of the Federal Code stipulates that medication error rates at nursing homes must not be “5 percent or greater.” A September 10, 2021 citation found that Throgs Neck Rehabilitation & Nursing Center failed to ensure such. The citation states specifically that one resident “was not administered with six (6) of the prescribed medications due” during an observation. The citation states further that the Licensed Practical Nurse administering the resident’s medications did “not inform the resident that some medications were not being administered at that time.” In an interview, the LPN told a state health inspector that “the missed medications were not available in the medication cart and they should have informed the resident.” The LN added that they planned to search for the medications or contact the facility’s pharmacy to confirm when the medications were re-ordered, or to re-order them if necessary. In an interview, the facility’s Director of Nursing stated “that the nurses are supposed to follow up and get medication before they are exhausted, and they did not know why the staff are not doing that.” A plan of correction undertaken by the facility included the ed-education and in-servicing of relevant staff. 

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Ontario Center for Rehabilitation and Healthcare has been issued a fine and has received a total of 77 citations since 2017 for failing to keep the residents safe from falls and accidents, for failing to treat and prevent pressure ulcers, and for failing to administer medication in a timely manner.

Ontario Center for Rehabilitation and Healthcare has received 77 citations for violations of public health code between 2017 and 2021, according to records accessed on December 4, 2021. It was also issued a $12,000 fine in 2016 over findings it violated health code provisions regarding medication errors and resident rights. The Canandaigua nursing home facility’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 adequately protect residents from accidents. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with adequate supervision and assistance devices to prevent accidents. A June 2021 citation found that Ontario Center for Rehabilitation and Healthcare failed to ensure such. The citation specifically describes a resident on aspiration precautions who was not provided with supervision at mealtimes, and another resident who “did not receive assistance with ambulation and transfers to minimize risk of falls.” The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the counseling of the residents’ care staff. 

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Houghton Rehabilitation & Nursing Center was fined in 2016 and has received a total of 18 citations in the last four years from multiple state inspectors for being in violation of public health code and for failing to properly care for its residents.

Houghton Rehabilitation & Nursing Center has received 18 citations for violations of public health code between 2017 and 2021, according to records accessed on December 4, 2021. It was also issued a $12,000 fine in 2016 over findings it violated sections of the health code relating to quality of care. The Houghton nursing home facility’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 care. Section 483.25 of the Federal Code requires nursing homes to ensure residents with pressure ulcer receive necessary treatment and services to prevent infection, promote healing, and stave off the development of new ulcers. A September 2018 citation found that Houghton Rehabilitation & Nursing Center failed to ensure such for one resident. The citation states specifically that when a physician ordered treatment for a resident with a Stage 3 pressure ulcer, the treatment was not provided as ordered, and further that the resident was not provided with a pressure-relieving air mattress per the wound consultant’s recommendation. A plan of correction undertaken by the facility included the completion of the treatment and provision of the bed. 

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Livingston Hills Nursing and Rehabilitation Center has been cited 66 times since 2017 for failing to properly care for patients’ pressure ulcers and for failing to take proper preventative measures to avoid any further injuries or infections.

Livingston Hills Nursing and Rehabilitation Center has received 66 citations for violations of public health code between 2017 and 2021, according to records accessed on November 12, 2021. It was recently placed on the “Special Focus Facility” list maintained by the Centers for Medicare and Medicaid Services. The Livingston nursing home facility’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 provide adequate pressure ulcer care. Section 483.25 of the Federal Code requires nursing homes to ensure residents receive a professional level of care and services to promote the healing of existing pressure ulcers and prevent the development of new pressure ulcers unless medically unavoidable. An April 2019 citation found that Livingston Hills Nursing and Rehabilitation Center failed to ensure such. The citation specifically states that the nursing home did not provide adequate interventions to prevent or promote the healing of a pressure ulcer on a resident’s coccyx. The citation describes the lack of interventions added to the resident’s care plan after the resident was documented as at risk for a pressure ulcer; a review found additionally that after an ulcer was documented, there was “no care plan for the necrotic wound and/or the wound infection.” In an interview, the facility’s Medical Director said “he was not aware that there were no wound care orders to promote healing of the pressure sore” and that the resident “received a substandard of care.” A plan of correction undertaken by the facility included the education of all nursing staff. 

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A recent report has found that nursing homes across the country are vastly understaffed and they are not receiving citations for going against regulations.

A new report by the Long-Term Community Care Coalition has found that while insufficient staffing is a widespread problem in nursing homes, state nursing home surveyors rarely issue citations for it. The report, titled “Broken Promises,” analyzes nursing home citations from 2018 until 2020.  Continue reading

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A recent report found that over 90,000 nursing home patients across the country are suffering from pressure ulcers and local health departments are not issuing citations for staff failing to prevent and care for these open sores that could potentially be harmful to patients.

A new report by the Long Term Community Care Coalition reveals that nearly one in ten nursing home residents have unhealed pressure ulcers. According to data analyzed by the organization, 7.92% of nursing home residents in the United States, or approximately 92,000 people, are suffering from unhealed pressure ulcers. The LTCCC suggests that this figure is “likely a significant undercount, since studies have found that many nursing homes under-report these data.” Continue reading

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A recent report shares that federal data from nursing homes across the country has agencies mostly concerned about the use of antipsychotic drugs, failure to control infection, failure to prevent and properly care for pressure ulcers, and issues with insufficient staffing.

The Long-Term Community Care Coalition recently released a report analyzing federal data concerning the oversight of nursing home facilities across the country. The report draws high-level conclusions about nursing home surveys and enforcement actions taken by state, regional, and federal regulatory authorities. Specific enforcement areas concerned include antipsychotic drug use, infection control, pressure ulcer care, staffing issues, and resident rights. Continue reading

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Highland Rehabilitation and Nursing Center has received 26 citations since 2017 for being in violation of public health codes and for failing to properly take care of its residents.

Highland Rehabilitation and Nursing Center received 26 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on October 22, 2021. The Middletown 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 deliver adequate pressure ulcer care and prevention measures. Under Section 483.25 of the Federal Code, nursing homes must ensure residents receive necessary treatment and services to prevent the development of pressure ulcers unless they are medically unavoidable. A January 2020 citation found that Highland Rehabilitation and Nursing Center failed to ensure such. The citation states specifically that the nursing home failed to establish and perform interventions tailored to one resident’s particular circumstances to prevent the development of pressure ulcers. It goes on to state that in connection to a second resident, the nursing home failed to ensure the use of heel booties to promote the healing of pressure ulcers and prevention of further ulcers from developing. The citation states that these deficiencies, while isolated, had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the in-servicing of residents and the updating of the first resident’s care plan. 

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