Villagecare Rehabilitation and Nursing Center Cited for Pressure Sores

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.

2. The nursing home did meet infection prevention and control standards. Under Section 483.80 of the Federal Code, nursing homes “must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” A December 2019 citation found that Villagecare Rehabilitation and Nursing Center did not adequately maintain infection control practices. An inspector specifically observed that a resident’s “ostomy urine drainage bag was… touching the floor in the resident’s rom,” in contravention of catheter care policies. In an interview, a Licensed Practical Nurse stated, “The drainage bag is not supposed to be touching the floor. This is an infection control issue.” In another interview, one of the facility’s Registered Nurses said, “It is on the floor because the bed is on the lowest position for his safety. The bag should be hanging off the siderail about 6 inches off the floor. This is an infection control problem. I will change the bag and elevate the bed, so the new drainage bag does not touch the floor.” The citation states that this deficiency had the “potential to cause more than minimal harm.”

3. The nursing home’s cooking facilities did not comply with safety regulations. Section 101 of the NFPA sets standards for ventilation control and fire protection in cooking facilities. A March 2018 citation found that Villagecare Rehabilitation and Nursing Center did not comply with this regulation. An inspector specifically found that the facility’s “piping/nozzle system installed for the fire protection of cooking equipment in the kitchen” were not “secured tightly as to prevent accidental movement by hand.” The citation notes that piping and nozzles must be installed in such a manner that they cannot be moved by hand. In an interview, the nursing home’s Director of Facilities said that “the fire suppression system company was contacted” and the systems would be adjusted so that they could not be accidentally moved.

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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