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The Plaza Rehab and Nursing Center received 21 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 7, 2019. The facility was also the subject of a 2010 fine of $6,000 in connection to findings concerning staff treatment of residents, the quality of care it provided to residents, and its organizational and administrative practices. The Bronx nursing home’s citations resulted from a total of six inspections by state authorities. The violations they describe include the following:

1. The nursing home did ensure residents were protected from abuse. Section 483.12 of the Federal Code states that nursing homes must ensure residents’ freedom “from abuse, neglect, misappropriation of resident property, and exploitation.” A February 2019 citation found that The Plaza failed to ensure a resident’s freedom from staff abuse in a 2018 incident. The citation specifically describes an exchange in which a resident hit a Certified Nursing Assistant, and the Assistant “retaliated and hit” the resident in return. This contravened the facility’s “zero tolerance policy regarding abuse,” including hitting and slapping, according to the findings. The citation states that the deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not ensure the provision an environment for residents that was free of accident hazards. Under Section 483.25 of the Federal Code, nursing homes must ensure residents’ right to a setting free from accident hazards and with adequate staff supervision to prevent residents from sustaining accidents. A January 2019 citation found that the facility failed to ensure this right in a 2019 instance in which it did not prevent a resident’s elopement. The citation specifically states that at 3:21 AM on the night in question, the resident exited the facility undetected through a “back loading-dock door.” Staff discovered the resident’s absence at approximately 4:00 AM, and were notified by the hospital at 11:35 PM that night that the resident was in its emergency rom. A plan of correction undertaken by the facility included the termination of a security officer.

Triboro Center for Nursing and Rehab received 37 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 7, 2019. The facility was also the subject of a 2010 fine of $6,000 in connection to findings regarding pressure sores and the quality of care provided to presidents. The Bronx nursing home’s citations resulted from a total of three inspections by state authorities. The violations they describe include the following:

1. The nursing home did not adequately implement accident prevention protocols. Section 483.25 of the Federal Code stipulates that nursing home residents’ environment must remain “as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.” A June 2016 citation found that the nursing home failed to protect residents from accident hazards. An inspector specifically found that one resident’s furniture had “sharp screws and splintered wood”; that bleach was present in another resident’s bathroom; and that a resident sustained a fall resulting from clothing that was too large. The citation described this deficiency as resulting in “potential to cause more than minimal harm.”

2. The nursing home did not properly store and label drugs and biologicals. Section 483.45 of the Federal Code states that nursing homes must label drugs and biologicals “in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date.” A 2016 citation found that the nursing home failed to properly label and dispose of drugs and biologicals after they were expired. An inspector specifically observed a refrigerator with an open vial of a certain drug; and an open and undated vial of another drug. The citation noted that the drug manufacturer’s recommendation stated that if the drug “has been opened and in use for 1 month,” it “should be discarded because oxidation and degradation may have reduced the potency.” The citation describes this deficiency as resulting in the “potential to cause more than minimal harm.”

The Chateau at Brooklyn Rehabilitation and Nursing Center received 35 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 7, 2019. The facility was also the subject of a 2016 fine of $14,000 in connection to “multiple deficiencies” described in a May 2012 survey, including deficiencies in the quality of care provided to residents and in the nursing home’s quality assessment and assurance protocols. The Brooklyn nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not ensure sufficiently low medication error rates. Section 483.45 of the Federal Code stipulates that nursing home facilities must maintain medication error rates below five percent. A December 2016 citation found that the nursing home failed to stay below this threshold. An inspector specifically found that a resident “did not receive medications ordered for [a] specific diagnosis” in connection to “2 of 26 medication opportunities,” leading to a medication error rate of 7.4 percent. According to the citation, a nurse did not administer a certain medication, stating later that she had run out of the medication the previous day and submitted an order to the pharmacy for a refill; however, according to the findings, the facility “did not have an automatic system” to refill resident medications.

2. The nursing home did not employ adequate infection prevention and control protocols. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program” that establishes a “safe, sanitary and comfortable environment” for residents. A June 2019 citation found the facility did not maintain adequate infection control practices in an instance in which a resident with physician-ordered “contact precautions” lacked clear signage on their room. According to the citation, the room should have had signage “either identifying the category of transmission-based precautions, instructions for use of Personal Protective Equipment (PPE), and/or instructions to see the nurse before entering.” An inspector observed a visitor in the resident’s room, sitting near the resident and eating a sandwich, but without wearing a gown or gloves. The citation states that the signage that should have been on the resident’s door was in fact on a cart outside the room, partially obscured by a container.

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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Williamsbridge Center for Rehabilitation and Nursing received 29 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. These citations include one that authorities determined to reflect “a severe, systemic deficiency.” The Bronx nursing home’s citations resulted from a total of four inspections by state authorities. The violations they describe include the following:

1. The nursing home did not provide an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide an environment as free as possible from accident hazards, and to provide proper supervision to prevent accidents. A citation issued on April 23, 2019 found that the nursing home failed to adequately supervise a resident with a history of attempted elopement, who eloped from the facility on April 5, 2019. According to the citation, the resident was not accounted for during an 11 AM head count, and the nursing home did not launch a search for the resident until 2:30 PM. As of the date of the citation, the resident’s whereabouts remained unknown. The Department of Health found that this failure resulted in “immediate jeopardy to resident health or safety” and reflected a systemic deficiency.

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Beth Abraham Center for Rehabilitation and Nursing received 30 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. The Bronx nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not properly ensure the prevention and control of infection. Under Section 483.80 of the Federal Code, nursing home facilities “must 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.” During a May 2019 inspection, a surveyor observed a Licensed Practical Nurse “performing blood pressure monitoring for 3 residents without cleaning the blood pressure cuff between residents”; another LPN administering eye drop medication without maintaining “proper hand hygiene”; and a third LPN failing to maintain proper hand hygiene while completing a wound care observation.

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The Citadel Rehab and Nursing Center at Kingsbridge received 19 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. Those citations include two that were found to cause immediate jeopardy to resident health, and one that authorities say reflected “a severe, systemic deficiency.” The Bronx nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not ensure it provided an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide residents with an environment as free as possible from accident hazards, and with proper supervision and assistive devices to prevent accidents. An August 2016 citation states that an inspector observed more than 50 beds with siderails whose measurements “exceeded the FDA recommendation that spaces between the bed siderail bars should be no larger than 4 3/4 inches.” While the Department of Health inspector found that this deficiency had so far not resulted in actual harm, it had “the potential for more than minimal harm that was immediate jeopardy and substandard quality of care.”

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The Senate Finance Committee examined the “crisis” of nursing home abuse in an emotional hearing this month. Families of abused nursing home patients told their tragic stories and frustrations with the lack of government oversight. In one of the testimonies before the Senators, Maya Fischer tearily detailed the sexual assault her mother suffered at a five-star rated nursing home in Minnesota. According to prosecutors who later charged a nursing home staffer for the rape, the predator had been suspended three times by the nursing home while they investigated sexual assault allegations. In two of these instances, the nursing home staffer who attacked Fischer’s mother was the main suspect.

Fischer described her “final memories of my mother’s life… watching her bang uncontrollably on her private parts for days after the rape, with tears rolling down her eyes, apparently trying to tell me what had been done to her but unable to speak due to her disease.” According to CNN, Fischer’s mother suffered from Alzheimer’s disease. Fischer says she is now speaking out to prevent her family’s tragedy from occurring to anyone else.

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All nursing homes that receive more than $10,000 are required by federal law to report any suspicion of crimes against their elderly residents. While there have been reporting problems, the Department of Health and Human Services has vowed to increase enforcement of these federal regulations.

The mandatory reporting requirement, originally a part of the Affordable Care Act, more colloquially known as Obamacare, has two main provisions – both of which carry heftier fines as of November 28, 2017. A violation of these laws can result in a fine of up to $221,000. If the failure to report the suspected crime results in more harm to the resident, the fine increases to $331,000. The assisted living facility will also be fined for retaliating against any employee or resident that reports a suspected crime. The maximum fine allowable for a retaliatory measure is $221,000. Continue reading

Three nursing home employees in Nassau County have been arrested in connection with the death of nursing home resident at A. Holly Patterson Extended Care Facility.  Registered nurses, Sijimole Reji and Annieamma Augustine and certified nurse aide, Martine Morland were charged with neglect and endangerment of a resident. The patient relied on a mechanical ventilator to breathe and was completely dependent on the facility’s staff.

On December 20, 2015, the wheelchair bound resident became disconnected from her ventilator, setting off audio and visual alarms to alert staff of a life-threatening situation. The three employees were at the nursing station when the alarms sounded, however they did not immediately respond. Staff ignalarm-300x200ored the resident’s alarm for over nine minutes before they attempted to provide assistance to the patient. The resident was found unresponsive and unconscious; she was then transferred to Nassau University Medical Center, where she died the next day. Continue reading

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