Tolstoy Foundation Rehabilitation and Nursing Cited for Medication Errors

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The nursing home in Valley Cottage, New York has received 49 citations since 2017.

Tolstoy Foundation Rehabilitation and Nursing Center has received 49 citations for violations of public health code between 2017 and 2021, according to health records accessed on April 16, 2021. The Valley Cottage nursing home’s citations resulted from a total of two inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not adequately protect residents from accident hazards. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with an environment as free as possible of accident hazards and with adequate supervision to prevent accidents. A December 2019 citation found that Tolstoy Foundation Rehabilitation and Nursing Center failed to ensure such. The citation states specifically that one resident who was observed smoking cigarettes outside the building’s rear entrance “did not have a safe smoking evaluation completed since admission” and that his “comprehensive care plan did not include safety measures for smoking including the use of cigarettes and lighters.” In an interview, the resident stated he had never been spoken to regarding the nursing home’s smoking policies. A Certified Nursing Assistant said in an interview that he was not aware where the resident kept his smoking materials, had never asked if the resident was allowed to smoke, and had never been directed regarding the resident’s smoking status. A Registered Nurse manager stated in a separate interview that she was not aware whether a smoking assessment had been or should be performed for the resident, nor “who was responsible for completing the smoking care plans.” A plan of correction undertaken by the facility included a safe smoking evaluation of all smoking residents.

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The nursing home citation’s concerned a resident’s cigarette use, medication errors, and more.

2. The nursing home did not adequately prevent medication errors. Under section 483.45 of the Federal Code, nursing home facilities must ensure that medication error rates do not reach or exceed five percent. A December 2019 citation found that Tolstoy Foundation Rehabilitation and Nursing Center failed to ensure such. The citation states specifically that a medication error rate of 15% was observed in one particular medication pass. It goes on to describe an incidence in which a Licensed Practical Nurse administered a resident the incorrect concentration of a certain medication; an incidence in which a resident was administered eyedrops at the wrong time; an incidence in which an LPN crushed a resident’s medication tablets without a physician’s order for such; and an incidence in which a resident’s pill was administered via spoon, in contravention of a physician’s orders directing that the capsule be opened and sprinkled onto the resident’s apple sauce. A plan of correction undertaken by facility included the counseling of relevant staff.

3. The nursing home did not take adequate steps to prevent infection. Section 483.80 of the Federal Code requires nursing homes to establish a program designed to prevent the development and transmission of diseases and infections. A December 2019 citation found that Tolstoy Foundation Rehabilitation and Nursing Center failed to ensure such. The citation states specifically that the nursing home “did not develop a site-specific water management plan for Legionella.” It goes on to describe a review of facility records, including an email from a contractor who documented that a November 2019 legionella compliance test uncovered results “at 60% exceeding the New York State (NYS) standard of 30% positives.” A plan of correction undertaken by the facility included the counseling of the facility’s Director of Environmental Services.

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents.  Please contact us to discuss in the event you have a potential case involving neglect or abuse.

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