Inspection Report: Nursing Home Failed to Maintain a Clean and Safe Environment for Residents

According to a June 2013 report issued by the New York State Department of Health (DOH), the Saratoga Hospital Nursing Home, a 36-bed facility located in Saratoga Springs, New York, failed to maintain a safe, clean and homelike environment for its residents. In particular, DOH inspectors stated that the shower room used by many residents was dirty and not properly maintained. For instance, inspectors noted that mold was on the shower tiles and floor. A metal shelf, the shower door, and a grab bar had peeling paint and were rusty; a ceiling tile was also missing. In addition, inspectors noticed that an air vent was covered with plastic wrap and cut tape, preventing the air in the shower room from being properly circulated. The maintenance director and an administrator of the facility stated that they were unaware of the shower room’s condition. The nursing home fixed the room in July 2013 as a result of the DOH inspection.

During the same certification survey, the DOH also cited the nursing home for failing to “maintain practices that provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection.” For example, while talking to the nurse in charge of the facility’s infection control program, a DOH inspector observed a maintenance worker wheeling a large uncovered trash bin filled with garbage through the hallway; the infection control nurse stated that the trash bin should have been covered. When questioned by a DOH inspector, the worker wheeling the bin stated that he usually covers it but that he was “behind” that particular day and was in a rush.

hospital lady.jpgIn another related finding, a DOH surveyor determined that the facility failed to provide staff members and visitors with detailed instructions pertaining to patients who had Contact/Isolation Precautions due to sickness and infections. There were four such residents in the facility. Signs outside the doors of two of these patients instructed visitors to wear a mask, gloves and a gown. Two different residents with such precautions did not have detailed instructions outside of their rooms. The infection control nurse stated that she was not aware of this matter and needed to look into the issue.

DOH investigators also cited the nursing home for failing to provide timely treatment to a dementia patient who lost a significant amount of weight over a short period of time. When the patient was first admitted into the facility, the registered dietician noted that the patient, who was only five feet tall, was at risk of malnutrition and unintended weight loss. The dietitian stated that the resident was to receive daily nutritional supplements. DOH surveyors found no documentation that the resident ever received the supplements. In addition, on February 14, 2014, the resident weighed 109.4 pounds. On March 1, 2013, the resident weighed 106.1 pounds. On April 2, 1013, the resident only weighed 100 pounds–an 8.6 percent weight loss in a two month period. The dietitian stated that the resident should have been weighed more frequently so that the issued could have been addressed and treated sooner.

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