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ALERT: Nursing Home Care at Watch List Facilities ‘Absolutely Shameful’

FFBC PRESS RELEASE

FOR IMMEDIATE RELEASE
November 30, 2016  |  850.491.0066
[email protected]

 

(AUSTIN, TX) – The Center for Medicare and Medicaid Services recently updated its Special Focus Facility list to expose those nursing homes across America which are repeatedly beleaguered with “serious problems.”

watchlistlogo“The quality of care at these watch list homes is absolutely shameful,” said Brian Lee, executive director of Families for Better Care.

The Special Focus Facility list also serves as a federal consumer alert to highlight which nursing homes are to be targeted for increased regulatory oversight by surveyors until satisfactory compliance is achieved by operators named on the list.


“Many of the horrific incidents of abuse and neglect could have been prevented.”


“What’s most painful about this list is that many of the horrific incidents of abuse and neglect that occurred in these watch list facilities could have been prevented if owners adequately staffed and properly trained employees at these homes,” Lee continued.

Nearly half of the nursing homes recently added to the Special Focus list were rated as below average or much below average in direct care staffing levels according to data collected by the Center for Medicare and Medicaid Services.  Inadequate staffing is a primary contributor to poor nursing home care.

“The best way to show respect to our parents and grandparents living in nursing homes is to hire enough caregivers to sufficiently meet their care needs,” Lee stated.

Families for Better Care encourages those families with loved ones in watch list homes to frequently share your concerns with nursing home administrators and staff, long-term care ombudsmen, and state survey agency personnel to ensure their loved ones are receiving the safest care possible—especially while these homes are spotlighted on the Special Focus Facility list.

The most recent additions to the Special Focus Facility list for each state include:


CALIFORNIA

Sky Harbor Care Center-Yucca Valley
Total Health Deficiencies – 15
Total Federal Penalties – $30,001
Overall Rating – 1 star
Summary of serious survey findings:

December 15, 2015-A caregiver verbally assaulted resident when he “yelled and cursed” at him and then continued to argue with the resident instead of following walk-away protocol to ensure resident’s safety.  The aide was suspended and eventually terminated.

 December 14, 2015-Facility failed to adequately monitor the whereabouts of a resident with dementia who was prone to wandering.  The resident eloped from the facility and was later found in the bushes outside of the facility where his wheelchair “landed on top of him, resulting in swelling of his eye and bleeding from his head.”  The resident was transferred to the hospital where he required admittance to the intensive care unit “due to the injuries sustained” in his fall.


FLORIDA

Palm Garden of Winter Haven (Winter Haven)
Total Health Deficiencies – 6
Total Federal Penalties – $175,525
Overall Rating – 2 stars
Summary of serious survey findings:

October 31, 2014-“A resident with Alzheimer’s Disease was physically abused by six staff members on seven different occasions.”  The resident was hospitalized with “skin tears and bruising up and down his arms, from his knuckles to his elbows.”  The concerned resident’s family installed a hidden camera in the resident’s room and recorded several abusive incidents by a number of caregivers.  During one event, two caregivers entered the resident’s room.  One employee “put her hand over the resident’s face swiping down over his nose in a provoking manner and then striking his left upper arm . . . [the employee] then made two quick jabbing punches toward his face.”  The family shared this recording and nearly 12 hours of other video with a local advocacy group and also used it to confront facility representatives.  State officials found that Palm Garden of Winter Haven failed to “take steps to detect, prevent and report abuse.”

University Center East (Deland)
Total Health Deficiencies – 14
Total Federal Penalties – $382,480
Overall Rating – 1 star
Summary of serious survey findings:

May 8, 2015-Widespread medication errors, sloppy medication records, and numerous “medication variances.”  These divergences were associated with a licensed practical nurse who allegedly stole residents’ “controlled drugs” and, on one occasion, was found “staggering, stumbling, and slurring her words” after she returned to her shift following her break.  Residents alerted facility personnel that they had not received prescribed medications as many as “six or seven times” over a three-month period, but the facility failed to properly document the residents’ complaints.  One employee told state inspectors that she was uncertain if 22 residents received their “evening Insulins or medications” during one of the shifts the nurse worked.  The facility later terminated the nurse’s employment for “not documenting” because the administrator “could not prove she took the medications” from the nursing home.


GEORGIA

Northeast Atlanta Health and Rehabilitation Center (Atlanta)
Total Health Deficiencies – 17
Total Federal Penalties – $234,521
Overall Rating – 1 star
Summary of serious survey findings:

January 21, 2016-Facility delayed initiating lifesaving protocols for a resident more than an hour after he was found unresponsive by staff.  Nursing home records show that the resident called for help and rang his call light numerous times over a 30-minute period prior to his death with no response or assistance by staff.  After the resident’s death, staff did take time to “put a pillow case on the resident’s pillow . . . place it under his head . . . wash his face and lips . . . arrive with a CPR backboard, but did nothing . . . adjust his oxygen tank . . . and could be heard laughing” before paramedics arrived, whereupon they began chest compressions.


ILLINOIS

Cahokia Nursing and Rehab Center (Cahokia)
Total Health Deficiencies – 20
Total Federal Penalties – Payment Denials
Overall Rating – 2 stars
Summary of serious survey findings:

July 12, 2016-Facility staff failed to evacuate 14 residents after a fire broke out at the nursing home.  Staff also neglected to immediately notify fire safety personnel that numerous residents were left inside the burning building.  Several residents suffered fire related injuries and required subsequent hospitalization.  State surveyors determined that the facility failed to adequately train caregivers on how to respond to an actual fire, resulting in “poor communication and prolonged relocation of all 106 residents.”

Timbercreek Rehab and Healthcare Center (Pekin)
Total Health Deficiencies – 53
Total Federal Penalties – $36,355; Payment Denials
Overall Rating – 1 star
Summary of serious survey findings:

March 5, 2015-A resident suffered a burn from a wall heater that registered more than 160 degrees.  Four or five residents were in jeopardy of suffering similar injuries due to the facility’s failure to maintain the “hallway heaters to prevent a thermal hazard to independently mobile residents.”


KENTUCKY

Barkley Center (Paducah)
Total Health Deficiencies – 6
Total Federal Penalties – $299,390; Payment Denials
Overall Rating – 1 stars
Summary of serious survey findings:

February 13, 2016-Facility failed to follow a resident’s Advance Directive wishes that required CPR to be initiated if the resident experienced a cardio or respiratory attack.   On the date of the resident’s death, a nurse discovered the resident unresponsive and decided not to start CPR despite the resident’s previously documented wishes.  The nurse determined for herself that the resident’s lack of pulse negated the resident’s CPR request.  Paramedics responding to the 911 call for assistance questioned the nurse’s decision to prevent CPR.  Emergency personnel transported the resident to the hospital for treatment, attempting multiple emergency interventions to simulate the resident’s heart, but to no avail.  Interviews with facility personnel revealed that the nurse countermanded the resident’s Advance Directive wishes, questioning what quality of life the resident would enjoy if CPR was used to save the resident. 


MASSACHUSETTS

Kindred Transitional Care and Rehabilitation (Avery)
Total Health Deficiencies – 19
Total Federal Penalties – $163,833; Payment Denials
Overall Rating – 2 stars
Summary of serious survey findings:

January 29, 2016-The facility failed to sufficiently train staff to respond to an emergency coronary episode for one resident.  The facility also failed to ensure all emergency equipment was available on the emergency cart by not verifying needed supplies were adequately stocked on the cart for eight months.  Seven of the 22 items needed on the cart were listed as missing.  Inadequate supplies prevented staff from utilizing an emergency compression board required to properly administer CPR.  Furthermore, the emergency cart was not nearby, located two floors above the occurrence of the resident’s heart attack, and staff waited a prolonged period to start CPR while caregivers worked to track down the resident’s medical record to validate code states.


MINNESOTA

Chris Jensen Health and Rehabilitation Center (Duluth)
Total Health Deficiencies – 6
Total Federal Penalties – $33,985; Payment Denials
Overall Rating – 1 star
Summary of serious survey findings:

January 29, 2016-A resident suffered a “cervical neck fracture” after the facility failed to “conduct ongoing comprehensive fall assessments” as a precaution to prevent injuries for a resident known to be at high risk for falls.


NORTH DAKOTA

Minot Health and Rehab, LLC (Minot)
Total Health Deficiencies – 26
Total Federal Penalties – None
Overall Rating – 1 star
Summary of survey findings:

August 4, 2016-Every resident and family member interviewed by state inspectors during a complaint investigation expressed a common concern that the facility failed to promptly respond to call lights, resulting in “avoidable incontinence” for several residents.  Residents’ comments regarding the length of time they waited for assistance included: “The facility is short staffed . . . staff will turn (the call) light off and not come back. Had to wait over an hour . . . I call my son and daughter to telephone the facility to assist me”; “At maximum it takes an hour and a half to answer”; “Sometimes they’ve been slow. They can’t help it. They’re so short-staffed”; and “Hour and something . . . several accidents, (the) poopy kind . . . (I was) mad, embarrassed. I’ve told a few of them (staff members) off already”.


NEBRASKA

Good Samaritan Society (Alliance)
Total Health Deficiencies – 15
Total Federal Penalties – $23,920; Payment Denials
Overall Rating – 2 stars
Summary of serious survey findings:

July 6, 2016-The facility failed to safely care for a resident with a history of falls.  The resident was “left unattended” and subsequently fell.  The resident sustained a dislocated hip, head laceration, and brain bleed as a result of improperly implemented safety interventions by facility staff.


OHIO

The Manor at Whitehall (Whitehall)
Total Health Deficiencies – 45
Total Federal Penalties – $16,143
Overall Rating – 1 star
Summary of serious survey findings:

May 12, 2016-The facility failed to protect a resident from verbal and physical abuse.  A resident “sustained actual harm” when a caregiver threw the resident into a wheelchair and yelled profanities at the resident.  An investigation by facility administration revealed that the caregiver suffered “burnout” and was actively displaying frustration toward fellow workers, shouting expletives toward them just moments before she abused the resident.  Successful implementation of the facility’s “Managing Employee Burnout Protocol” may have resulted in quicker intervention with the employee and prevented abuse of the resident.


PENNSYLVANIA

Pembroke Health and Rehabilitation Center (West Chester)
Total Health Deficiencies – 11
Total Federal Penalties – $13,390
Overall Rating – 1 star
Summary of serious survey findings:

October 13, 2015-Hot water temperatures exceeded 110 degrees Fahrenheit for three of the facility’s nursing floors.  Improper maintenance by facility staff endangered the safety and welfare of numerous residents.


SOUTH DAKOTA

Golden Living Center – Meadowbrook (Rapid City)
Total Health Deficiencies – 32
Total Federal Penalties – $55,648
Overall Rating – 1 star
Summary of serious survey findings:

August 24, 2016-A certified nursing assistant (CNA) reported verbal and psychological abuse of a resident by two nurses to her supervisor, the director of nurses.  The CNA observed the two nurses mocking the resident’s speech, laughing at the resident, and yelling at the resident to be quiet.  As the resident pleaded to one nurse for assistance, the nurse mockingly yelled at the resident “Hello, Hello” as the other nurse watched and laughed.  The CNA told health inspectors that her after reporting the incident, her supervisor downplayed the abuse by failing to take disciplinary action against the employees to prevent residents from suffering additional harm.  Facility administrators acknowledged the incident and confirmed “an investigation had not been started” because the nurses in question told their supervisors “they were just being silly.” 


TEXAS

Hearne Healthcare Center (Hearne)
Total Health Deficiencies – 12
Total Federal Penalties – $94,540; Payment Denials
Overall Rating – 1 star
Summary of serious survey findings:

October 20, 2014-The facility failed to protect a resident from physical abuse.  Two caregivers harmed a resident by spanking him with their hands.  The employees continued to care for the resident despite his pleas that they were “rough with him,” called him a “troublemaker” and that he was someone who was just “hard to deal with.”  The resident was “fearful” for his safety when he interacted with the caregivers.  Another resident also reported that he was afraid of employees who “talk bad to him and call him names.”  He was so frightened to report the verbal abuse to a state health inspector that he asked for a pen and paper to write down his concerns.  He wrote that two caregivers call him a “motherf*****” and made fun of him because “he can’t do things for himself.”

The Lennwood Nursing and Rehabilitation Center (Dallas)
Total Health Deficiencies – 6
Total Federal Penalties – $194,260; Payment Denials
Overall Rating – 1 star
Summary of serious survey findings:

January 17, 2016-The nursing home failed to terminate an employee after a background check revealed that the individual had a negative “finding on the State nurse aide registry.”  The registry showed that the employee’s nurse aide certificate had been previously revoked and “she was unemployable in a licensed nursing facility in Texas.”  Facility administrators allowed the employee to work at the facility more than two months after the “facility had knowledge of her unemployable status.”  These failures by the facility “placed all 98 residents at risk for abuse, neglect, mistreatment, and/or misappropriation of property.”

West Houston Rehabilitation and Healthcare Center (Houston)
Total Health Deficiencies – 19
Total Federal Penalties – $27,593; Payment Denials
Overall Rating – 1 star
Summary of serious survey findings:

November 19, 2015-The facility neglected to implement precautionary interventions to prevent the neglect of five residents identified as potential fall risks.  These failures resulted in multiple falls and painful injuries to residents, including an “intraventricular hemorrhage and subdural hematoma” suffered by one resident.


UTAH

Lomond Peak Nursing and Rehabilitation Center (Ogden)
Total Health Deficiencies – 36
Total Federal Penalties – None
Overall Rating – 1 star
Summary of serious survey findings:

December 7, 2015-The facility had an exceedingly high frequency of medication errors observed during a medication pass.  Nearly 20 percent of the distributed medications were in error.  A medication error resulted in harm for one resident who was given a double dosage of a narcotic.  Prior to the over dosage, the resident was “awake and interactive”, but shortly after the medication error, staff found the resident “unresponsive, frothing at the mouth . . . with shallow breathing.”  Emergency medical personnel were contacted and transported the resident to the hospital for additional treatment.

For more information, visit our website at http://familiesforbettercare.com.

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ABOUT FAMILIES FOR BETTER CARE
Families for Better Care is a non-profit citizen advocacy group dedicated to creating public awareness of the conditions in our nation’s nursing homes and developing solutions to improve quality of life and care.