Nursing Home Abuse Lawyer Blog

Monique Jones and Nellie Weller

New York State continues its crackdown on nursing home abuse. Monique Jones and Nellie Weller were both arrested and charged with endangering the welfare of an incompetent or physically disabled person and willful violation of health laws. Jones is accused of kicking an 88 year old resident in the ribs while she was employed at Kirkhaven Nursing Home in Rochester, New York as a Certified Nurse Aide. Weller is accused of using a nightgown to tie a 76 year old resident's legs and arms, leaving him unable to move while employed as a Certified Nurse Aide at Edna Tina Wilson Living Center in Greece, New York. Both women have since been terminated from their employment.

Both women have been arraigned and were released on their own recognizance.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Raymond Parent was admitted in 2003 to Rhode Island Veterans Home in Bristol, Rhode Island in 2003. At that time he was incapable of making medical and financial decisions for himself. His daughter was granted the legal responsibility of caring for her father.

Mr. Parent's family is alleging that he suffered unsanitary conditions and underwent medical procedures that his family was not told about and did not approve. He underwent three colonscopies without his family's knowledge. It is alleged that the facility sometimes changed his legal status without notifying his family. Mold was discovered multiple times in the water pitcher next to Mr. Parent's bed and uncapped razors were discovered in his bathroom. Mr. Parent was taking blood-thinning medications and could bleed profusely if cut.

As Mr. Parent was dying, facility staff threatened to call state police and have Mr. Parent's granddaughter, Barbara Crowley, removed from the premises because she took photographs of bruising on her grandfather's arms.

Currently, the House Committee on Veteran's Affairs is investigating the facility after it was uncovered that the facility was having problems. Problems were occurring between management and staff, there was poor communication between staff and families, and structural problems with the building.

Christopher Mukdsi

In one of the worst neglect cases recently seen, Christopher Mukdsi faces felony murder charges. The neglect was so rampant that officials likened it to "living in a death camp" and it led to the death of Katherine Mukdsi in the June 2008.

Mrs. Mukdsi was found dead in her wheelchair on the front porch of her home in Flint Township, Michigan after her son called 911 to report her death. She had not moved from her couch in eight months prior to her death, but her son carried her outside to wash her down with a garden hose and placed her in a clean nightgown. He then wrapped his mother in a blanket and placed her in a wheelchair on the front port before emergency medical personnel arrived at her home. Her blanket was so caked in urine and feces that it still held the shape of her body when it was removed. She had not bathed in one year and was only allowed to urinate into a coffee cup and defecate into pizza boxes, some of which were still in the house. The 73 year old woman looked like she was 103 years old and had dwindled to just 63 pounds at her death. She was suffering from sepsis caused by feces that had entered into the open sores on her body. Police suspect that Mukdsi placed Mrs. Mukdsi on the front porch hoping that police would not enter the house. Trash was everywhere in the house and empty soda bottles were on tables and the floor. It looked as if trash had not been taken out in months.

An autopsy found sepsis, malnutrition, dehydration, complicating immobility and bed sore ulcers on Mrs. Mukdsi's body. She suffered from malnutrition, dehydration, and bed sores so severe that the skin and tendon were gone and her bone was exposed.

Katherine Mukdsi's son, Christopher Mukdsi, was her caregiver. He had lived with his parents off and on his entire life, but moved in permanently with his mother after his father's death in 2002. He had not worked in 10 years and was living off of his mother's Social Security check, a pension, and a monthly investment check. He spent six days in jail this month on a drug charge after police found cocaine on him while questioning him about his mother's death.

Christopher Mukdsi faces a possibility of life in prison if convicted of the murder charge and an additional four years if convicted of the additional charge of second degree abuse of a vulnerable adult. He was denied bond and remains in jail.

Lora Washburn

Lora Washburn, a former activity coordinator at Montrose Health Center in Montrose, Iowa, saw a co-worker verbally abusing an elderly resident. The aide was refusing to allow the resident to use a wheelchair and "was telling her she was pathetic, that it was ridiculous, that she could walk, that she shouldn't ask for a wheelchair". The resident was crying and the aide further told her "There are people here in this facility that are crippled and they need wheelchairs and you're going to walk and you're going to get to the dining room right now or you're not going to eat dinner". Lora did what she is required by Iowa's mandatory-reporter law - she reported the abuse to the facility administrator, David Payne. Reportedly, Administator Payne did nothing. When a state inspector visited the home to investigate Ms. Washburn's allegations, the investigator spoke to nurse Tammy Hopp, who admits that she did not tell the inspector everything and downplayed the event to protect the facility.

Ms. Washburn was fired a few days after making the report. Her boss accused her of trying to intimidate a co-worker into giving state inspectors information about the alleged abuse. The co-worker who actually admitted that she downplayed her report to the state to protect the nursing home was rewarded. Her reward? She was promoted.

Ms. Washburn filed for unemployment and her unemployment benefits hearing led to the reopening of the abuse investigation.

In another Iowa incident, Janice Rardin was the Director of Nursing at The Evangelical Free Church Home in Boone, Iowa. She was terminated from her job after she filed two complaints of suspected abuse. The alleged abuser? The Administrator of the facility, Ron Honson.

Allegedly, a few weeks after Ms. Rardin filed the second complaint, she overheard Honson telling the facility's attorney that he wanted to fire Ms. Rardin for reporting him. The attorney allegedly told Honson to wait until later so her termination did not appear as retaliation. Three months later, Ms. Rardin was terminated for eavesdropping on the conversation.

So what is the lesson? Report abuse and get fired. Cover up abuse and get promoted.

The biggest reason people don't report suspected abuse is fear of retaliation. By complying with Iowa's mandatory-reporter law, caregivers face possible termination. By simply violating the seldom enforced mandatory-reporter law, caregivers only face a $65 fine and potential licensing sanctions if the case is prosecuted. In fact, in the past ten years, no Iowa caregivers have been convicted of violating the mandatory-reporter law, even though dozens of abuse cases have been catalogued. In 2003, state inspectors found that employees at Bethany Lutheran Home in Council Bluffs, Iowa were barricading residents in their rooms at night. One resident had been tied to a urine-soaked bed with a rolled up bed sheet. In 2004, Harmony House in Waterloo, Iowa was fined by the state for failing to report sexual abuse of a male resident by an employee. Several suspicious incidents were reported to supervisors, who failed to report the incidents. The aide admitted to having sex with the resident. In 2005, a Friendship Manor Care Center employee in Grinnell, Iowa was convicted of sexually abusing residents of the home. One employee said she had seen the employee sexually touch residents "repeatedly, almost every day I worked with her".

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (314) 317-2525 or visit us at www.nursinghomejustice.com.

Karen Buck, a former certified nursing assistant (CNA) at Williamsburg Village nursing home, now doing business as Golden Living Center, faces an April 2009 trial on the felony charge of punching a 94 year old nursing home resident in the mouth. Buck allegedly punched Vera Talbott on June 2, 2007 after Ms. Talbott spit at her.

Ms. Talbott entered the facility after suffering a stroke. Her daughter visited her daily. One Saturday, her daughter found Ms. Talbott with a red face, food sitting in front of her, and drugged almost unconscious. The facility refused to tell her what was wrong with her mother's face. After her daughter left the facility, a nurse called her and told her they were sending her mother to the hospital and that a CNA had hit her. A detective later told her daughter that a fellow CNA saw Buck "slug and slap" Ms. Talbott in the face two or three times. Ms. Talbott suffered a black eye and other facial bruises.

Ms. Talbott died on September 2, 2007.

The family Alice Laverne Britton has filed a wrongful death lawsuit against Asbury Place for the 2008 death of Ms. Britton. The suit alleges that negligence contribute to Ms. Britton's death. She had been a resident of Asbury Place since 2005. The suit alleges that Ms. Britton did not receive proper nutritional care and was severely malnourished and dehydrated at her death in July 2008. The suit further alleges that two unskilled nursing employees dropped Ms. Britton, breaking her femur. Her injury went untreated initially.

In addition to the allegations listed above, Ms. Britton had bed sores that went untreated until they were severe. She was placed on hospice care on May 1, 2008 and once hospice became involved, the facility allowed Ms. Britton to "rapidly deteriorate" by relinquishing its duties.

The facility also faces allegations that the facililty failed to properly monitor and prescribe medication that caused Ms. Britton to bleed internally.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Peg Marino, former owner of St. Rita's Senior Care Community in Salem, Oregon, pled guilty to two counts of criminal mistreatment in connection to the theft of more than $58,000 belonging to four residents. She was sentenced January 22, 2009 to twelve months in prison and ordered to repay $50,000.

The Oregon Department of Human Services took control of the facility in 2007 and appointed a trustee to run the day-to-day operations. The facility's 48 residents were eventually moved to other facilities after substandard care and abuse allegations were uncovered.

Brianna Broitzman and Ashton Larson did not enter a plea on January 21, 2009 when they appeared in Court to face accusations of taunting residents and physically and sexually abusing at least fifteen residents suffering from dementia or Alzheimer's disease. Bail was set $6,000 for their unconditional release and $2,000 if the teens accept some restrictions. Both women say they will post bail and avoid jail time.

Casa Bonita Convalescent Hospital has been hit with a $121,000 fine after a patient was disconnected from a ventilator and died at the facility. The ninety year old resident died in October 2007 after a remote alarm was turned off and staff was not alerted when the ventilator was disconnected. The facility was issued three citations in the incident, one of which was a "AA" citation, which is the most severe penalty that a nursing home can receive. The facility was fined $100,000 for failing to have a system that prevented the patient from becoming disconnected from the machine and for turning off the ventilator's alarm. The facility also assessed a $20,000 fine for failing to check on the alarm system and a $1,000 fine for failing to implement staff policies that ensured ventilator education and certification. The California Department of Public Health said that poor care at the facility caused the resident's death. The facility dusputes this finding and plans to appeal

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Brianna Marie Broitzman and Ashton Michelle Larson made their first court appearance today for the alleged abuse of fifteen residents of Good Samaritan Society nursing home. Neither girl entered a plea on the pending charges. The women were ordered to report to the county jail by 5:00 p.m. today to be booked, fingerprinted, and photographed. Bail is set at $6,000 for unconditional release and $2,000 if the women accept restrictions on themselves. Both women say they will post bail to avoid jail.

After years of care problems at Minnesota's five veterans' homes, the Department of Veterans Affairs assumed control over the facilities in 2007. The Minneapolis facility alone was fined $42,300 between 2005 and 2007 and was cited for 66 state violations during that time.

Unfortunately, improvement is slow. New data shows that the fall rate at the Minnesota facility is nearly twice that of other veterans' facilties. That facility has also been unable to hire enough staff to keep overtime costs under control. A recent legislative audit report found that the Minneapolis facility had sloppy fiscal management and accounting, in addition to the care-related problems.

The Department of Veterans Affairs is considering whether or not to shift funding of the veterans homes to Medicaid for federal funding instead of the Department of Veterans Affairs. The Minneapolis home alone operates on a $35 million annual budget. A switch to Medicaid funding would change the current rule allowing veterans to give away their assets when moving into a veterans' facility instead of paying for their own care.

The State of Tennessee and the Department of Justice have reached a settlement that will end the Department of Justice's investigation into the care of our veterans at Tennessee-run veterans homes.

Admissions were halted last year to three veterans' facilities after investigators discovered that the staff failed to protect residents from violence between residents and manage aggressive behavior. At two of the three facilities, nutrition and hydration were sorely lacking and the facilities improperly used psychotropic medications, had improper pain management, and improper fall prevention.

The Justice Department found care at Tennessee's Humbolt and Murfreesboro facilities was "so grossly deficient that residents are, among other things, practically being starved and dehydrated to death". In one instance, a triple Bronze Star recipient died in May 2007 after becoming severely dehydrated and the staff failed to prevent the dehydration that contributed to his death. He was a resident of the Murfreesboro facility.

The investigation will end in eighteen months if the facilties' violations are corrected.

Friendship Haven in Fort Dodge, Iowa was slapped with a $10,000 state fine after a resident was injured stumbling in a bathroom on more than one occasion. The $10,000 fine was reduced after a federal penalty of $260 was imposed.

The resident was taken to the restroom by a nurse's aide on March 8, 2008. After the resident was seated, the aide turned to take the resident's dentures to the sink. When the aide turned back to assist the resident, the resident was standing and stumbling backward. The back of the resident's head struck a wall. The resident was later transported to Trinity Regional Medical Center and transferred to a Des Moines hospital for treatment of a broken arm, broken hip, and cut on the back of the head.

The resident returned to the facility on March 14, 2008. On March 25, the same resident suffered another injury when the resident stood up in the restroom and stumbled backward, striking the head on the wall. The resident died on April 2.

In another incident involving a resident, Agnes Thompson, 103, died on January 21, after falling just hours earlier. She fell while returning to bed after using the bathroom and suffered a cut to the head and a broken left hip. Iowa Department of Inspections and Appeals imposed a $8,000 fine, which was reduced to $5,200.

The Terry Law Firm is experienced in handling cases involving falls at nursing homes. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

We discussed the teenage abusers at Good Samaritan Society of Albert Lea in our previous blogs. The teenagers were involved in verbal, sexual, and emotional abuse of at least 15 residents at the facility who suffer from Alzheimer's disease and dementia. The two women allegedly spit water on residents, poked residents in their breasts, aggravated residents, and inappropriately touched residents in their genitals.

Ashton Larson and Brianna Broitzman, the teenagers charged as adults in the alleged abuse case at Good Samaritan Society of Albert Lea, will be arraigned in Freeborn County District Court on Wednesday, January 21, 2009. They face charges ranging from failure to report abuse to criminal abuse of a vulnerable adult and assault. Each woman faces ten or more charges, all of which are gross misdemeanors. Four other teenagers face charges as juveniles for mandatory failure to report suspected abuse.

Freeborn County Attorney Craig Nelson said at tomorrow's hearing, the judge will explain the charges both women face and Nelson intends to make a motion that the defendants be booked, photographed, and fingerprinted.

James Owen Spurlock, a former maintenance worker at Touchstone Farms in Hawkins, Texas, was convicted of two counts of aggravated sexual assault and sentenced to twenty years for each count on Tuesday, January 14, 2009. He will serve the terms concurrently.

Spurlock was accused of having sex with a 38 year old mentally disabled woman, who told her family that he was using sex "to help prepare her for marriage". The abuse was discovered when the woman began talking about it with her family. The Wood County Sheriff's Office investigated the matter and discovered that he had also victimized a 24 year old mentally disabled woman living there.

The facility, which could only house five residents at a time, was in the process of closing when the abuse was discovered. There were three residents living at the facility at the time - two women and a man. Spurlock was a six year employee at the facility and was in charge of maintaining the facility inside and out.

The Terry Law Firm is experienced in handling cases of nursing home sexual abuse. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

We discussed Winchester Centre for Health and Rehabilitation's recent sanction by the State of Kentucky for a Type A citation, the most serious violation the state can assess, in our recent blog. The citation resulted from a medication error, but no further details are known at this time. The Centers for Medicare and Medicaid have pulled funding effective February 7, 2009.

It is not the first time that Winchester Centre for Health and Rehabilitation has had problems. Winchester and three other facilities owned by Kindred Nursing Centers were investigated for problems. That investigation revealed problems such as untreated infections or delayed treatment of infections, serious injuries from improper use of restraints, failure to assess and treat wounds, failure to administer medicines, and lack of supplies to treat life-threatening conditions. A 2004 state settlement forced the facility to spend $3.7 Million upgrading its patient care and reimbursing Medicaid for fraud and abuse. The settlement terms ended in February 2008.

Marcos Alderete barged into Tulare Nursing and Rehabilitation Center and punched three wheelchair-bound patients in the face before running away. He was arrested later and charged with felony elder abuse, battery, and public intoxication. He was drunk and police believe he may have also sniffed paint.

Community Care, Inc., the owner of Charlotte Care Facility's Persons With Mental Illness unit in Charlotte, Iowa, has opted to close the facility, but will continue to operate its residential care facility.

Recently, Community Care, Inc. came under fire from the Iowa Department of Inspections and Appeals for two instances in which the Person's with Mental Illness (PMI) unit was fined $33,000. The PMI unit was fined $15,000 in June 2008 for an incident in which facility employees restrained a patient, who later died. In November 2008, the PMI unit was fined $18,000 for an incident in which a patient allegedly sexually harassed a female employee of Community Care who transported the resident to an appointment by herself. The fines were tripled because the violations had occurred previously in the past year. The facility was given a conditional license and was not allowed to take in any new patients.

The twenty year old facility is being closed because "the money is not available to us to adequately serve the people who desperately need this service", according to William Bonnes, Chief Executive Officer of Community Care, Inc. Bonnes said that the unit receives more acutely ill residents and more staff is required, which raises costs.

We discussed John Riems and pending sexual abuse charges in our previous blog. John Riems, a night shift supervisor and nurse at Concord Care and Rehabilitation Center in Toledo, Ohio, confessed to sexually violating more than 100 nursing home patients during his career. He could name twenty-three of his helpless victims. He was indicted on 15 counts of rape, three counts of sexual battery, three counts of patient abuse, one count of gross sexual imposition, and two counts of sexual penetration. He faced the possibility of 174 years in prison.

Initially, Riems alleged that he digitally penetrated his vitcims' rectums to assist them in removing fecal matter, but prosecutors and investigators said he did it for sexual gratification.

Trial was set to begin on Tuesday, January 20, 2009. Riems and his family were split on whether or not to go to trial. At the last minute, Riems opted not to put his family through a trial and took a plea deal using what is called an Alford plea on Friday January 16, 2009. An Alford plea allows Riems to maintain his innocence but recognizes that the State had ample evidence of guilt. By accepting an Alford plea, Riems will forgo trial at the risk of a more stringent sentence. Riems has been sentenced to twelve and a half years in prison.

Twelve Kansas nursing homes facilities earned more than ten deficiencies, according to the new rating system instituted by the The Centers for Medicare and Medicaid. The national average for deficiencies is nine and Kansas' average for deficiencies is 11.

The following facilities were cited with eleven or more deficiencies:

Riverview Manor, Oxford - 33

Regal Estate, Independence - 31

Good Samaritan, Winfield - 21

Westview Manor, Derby - 29

Kansas Masonic Home - 20

Life Care Center, Andover - 19

Cherryvale Care Center - 16

Medicalodges, Arkansas City - 15

Golden Livingcenter, El Dorado - 15

Legacy Park, Peabody - 15

Deseret Nursing & Rehab, Wellington - 13

Haysville Healthcare Center - 11

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please call us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Provena Cor Mariae Center is a 73 bed nursing home facility located in Rockford, Illinois. The facility is a three star facility according to the new rating system instituted by The Centers for Medicare and Medicaid, indicating an average facility. In both 2006 and 2008, Provena Cor Mariae Center exceeded the average number of illinois nursing home deficiencies, which is eight. In 2006, the facility garnered twelve deficiencies and earned thirteen deficiencies in 2008.

All nursing homes are legally required not to employ individuals who have been found guilty of abusing, neglecting, or mistreating residents. The facility must ensure that all alleged violations are immediately reported to the administrator of the facility and other officials in accordance with state law and are thoroughly investigated. Provena Cor Mariae Center failed at least one resident when it failed to investigate how a resident received a 8 cm skin tear on her arm and had no policy or system in place for staff to follow when investigating such an injury. After state intervention, the facility in-serviced all licensed nurses regarding injuries of unknown origin, incident reporting, and investigation of injuries. The Director of Nursing was forced to review all incident reports to verify adherence to facility policy and that injuries were thoroughly investigated.

All services provided or arranged by a facility must meet professional standards of quality. The facility failed at least one of its residents by failing to remove nitroglycerin patches prior to the application of a new patch. The resident affected had four nitroglycerin patches, instead of the one ordered. Moreover, the patches were found by the resident's physician - not facility nurses. After state intervention, all licensed nurses were in-serviced regarding the application and removal of patches and the Director of Nursing was forced to conduct random observances of 50% of applied patches per week to confirm if the patch application or removal was done correctly. In another 2008 incident, the facility endangered two residents when it failed to administer medications through the residents' gastrostomy tubes in a method to prevent g-tube clogs. After the state investigation in that incident, the facility was forced to inservice its nurses regarding the facility policy for Administration of Medications and the Director of Nursing will conduct weekly random observations of nurses administering medication via gastrostomy tube.

Every nursing home resident must receive the necessary care and services to attain and maintain the highest physical, mental, and social well-being possible. The state investigation highlighted the facility's failure to maintain this requirement in 2008 by identifying one incident when the facility failed to evaluate the effectiveness of pain medication and failed to clarify orders of when to use a resident's medication to control back pain. The resident's orders showed the resident was to have Hydrocodone APAP 5/325 every six hours, Hydrocodone APAP 5/500 as needed, and Tylenol 650 mg every four hours as needed. The facility pharmacist admitted that someone should have questioned the drug order regarding the Tylenol because the amount of Tylenol ordered exceeded what the resident should be taking at that age and due to the potential for respiratory depression. The facility Administrator admitted to state investigators that the facility did not have policies or procedures or a written program on pain management. As a result of the state intervention, the facility in-serviced all licensed nurses regarding pain assessment and documentation of the effects of pain relieving interventions. The facility implemented a communication tool between rehabilitation and nursing to transmit pain assessment data and the Director of Nursing was forced to conduct weekly audits monitoring pain assessments and effectivements of pain relief intervention.

In another 2008 incident, the facility failed to communicate and coordinate two diabetic residents' meal plans, blood glucose checks, insulin administration, and dialysis schedule for dialysis treatments and failed to follow up on the detailed nutrition report from the dialysis center. After state intervention, the facility was forced to develop a communication notebook to accompany the residents to each dialysis session. The facility was also forced to review the insulin schedule to assure that it does not conflict with dialysis and ensure that the orders are properly carried out. Progress reports from dialysis must now reviewed after each treatment session and meal plans will be developed for each dialysis patient to include meals while at dialysis.

All nursing home residents who are fed by a naso-gastric or gastrostomy tube are entitled to the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Provena Cor Mariae Center failed two of its residents in 2008 when it failed to continue resident tube feedings, flush tube with prescribed water amounts, and failed to keep a gastrostomy site free of drainage. The facility was forced to educate its nursing and therapy staff regarding the need to adhere to tube feeding schedules.

Nursing home residents who are unable to perform their activities of daily living are entitled to receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Provena Cor Mariae Center failed one of its residents in 2008 in this area when it failed to implement a specific plan for the transfer of a resident with multiple spinal compression fractures. Once again, the facility Administrator admitted to investigators that the facility did not have a policy or procedure related to transfer or gait belt use. Once the state intervened, the facility was forced to implement a communication tool between rehabilitation and nursing to transmit information regarding transfer ability and complete a lift profile for each resident. The Director of Nursing was forced to conduct a weekly audit monitoring the completion of the profile, functional level assessment, and posting of information.

Pressure sores are a danger to all nursing home residents. Nursing home residents are entitled to receive care that prevents the development of pressure sores or, if they have existing pressure sores, care that promotes healing, prevents infection and new sores from developing. Provena Cor Mariae Center's failure with one resident was highlighted in the survey documentation. In that case, a resident had a Stage IV pressure ulcer on his sacrum at admission. Provena Cor Mariae Center failed to properly assess and perform the daily treatment as ordered. After state intervention, the facility re-educated licensed nurses regarding skin assessment, accurate description of wounds, and following physician orders regarding dressing changes. The Director of Nursing was forced to conduct weekly audits of the residents and monitor their skin and dressing changes as ordered by the physician.

All nursing home residents are entitled to live in an environment free of accident hazards and receive adequate supervision and assistance to prevent accidents. Provena Cor Mariae Center failed to implement a monitoring/supervision plan for a resident at risk for aspiration. The facility failed to ensure that staff were knowledgeable regarding thickened liquids and feeding techniques to prevent aspiration. A resident at the facility who had vocal cord paralysis choked on her medications after the facility gave her whole pills instead of crushing them and a substance actually went into her lung tissue. A review of her chart found that her care plan did not document any special feeding techniques and allowed her to eat unsupervised in the dining room or in her own room. There were no approaches or interventions listed as to how nursing would monitor her for signs or symptoms of aspiration during meals. After state intervention, the facility re-educated nurses and CNAs for aspiration risk precautions and implemented an aspiration risk care plan that will be present in the dining room and resident's chart.

Nursing home residents are to remain free from unnecessary drugs. In 2008, one Provena Cor Mariae Center resident was affected when the facility failed to attempt behavioral interventions before discontinuing psychrotropic medications. The facility must also ensure that residents are free of any significant medication errors. They failed in this regard with respect to one resident when he ate lunch prior to receiving his insulin. After state intervention, all licenses nurses were educated regarding facility policy regarding medication administration and prevention of medication errors.

Provena Cor Mariae Center staff failed to change gloves and wash hands to prevent cross contamination during a resident's dressing change, passing and setting up resident meal trays, and while passing ice water. This was observed when a LPN was assisting a RN with wound care. The RN put on sterile gloves and then moved a soiled waste basket closer to the bed. Then the RN removed a soiled dressing from the resident's heel and handled a bottle of Betadine solution and clean gauze. The RN applied the Betadine to the clean gauze and put the Betadine bottle in her pocket. She then removed her gloves and, without washing her hands, placed fresh gloves on. After state intervention, all staff was educated regarding hand hygiene.

The Terry Law Firm is experienced in handling nursing home cases of abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Villa Care Center

Villa Care Center, a nursing home located in Fort Dodge, Iowa, has been slapped with an $18,000 fine by state regulators after an investigation revealed that the facility's staff failed to obtain prompt care for at least five residents last year.

One instance involved a resident who suffered a broken arm after a bulletin board fell from a wall and struck the resident on August 26, 2008. The resident did not undergo an x-ray of the arm until two days later.

In another incident, a resident fell out of a wheelchair and complained of pain for several days before receiving treatment. Other incidents involved a resident who was found on the floor and was not sent to the hospital for medical treatment until two days later and two residents with open sores on their bodies.

The Department of Inspections and Appeals charged the facility with failing to assess and provide timely interventions for residents that had the onset of adverse symptoms, failing to provide assistive devices and ensure residents received adequate supervision, and failing to provide wound care and prevent pressure sore development.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Northwoods Rehabilitation & Extended Care Facility, Hilltop is a 112 bed nursing home facility located in Niskayuna, New York that specializes in services in traumatic brain injury treatment and pediatric care. Northwoods is a one star facility, according to the new rating system instituted by The Centers for Medicare and Medicaid, which indicates a below average facility. Northwoods is also on the government watch list for nursing homes that have a history of persistent poor quality of care. These nursing homes have been selected for more frequent inspections and monitoring.

In November and December 2008, Northwoods was cited for medication errors and lack of care that resulted in actual harm to residents and requiring hospitalization. Following a November 2008 investigation, the state found that two licensed practical nurses gave insulin in September and October 2008 to two residents who were not diabetic. The residents went into shock and were rushed to the hospital for treatment. One of the nurses admitted to the facility's Director of Nursing that she was under the influence of a non-prescribed narcotic at the time when she administered the incorrect medication. Oddly enough, she denied making a medication error. That nurse is no longer employed by the facility and is under investigation by the Office of Professional Discipline. The other LPN involved in the incident has been prohibited from distributing prescription drugs to residents and also was referred to Office of Professional Discipline. The state investigation also revealed that nurses at Hilltop signed out narcotic drugs but did not document that they were dispensed.

In a December 2008 investigation, the state found that the facility did not document a resident's pressure sore. The wound became infected and the resident was admitted to the hospital.

Northwoods Rehabilitation & Extended Care Facility is only one of five nursing homes in the State of New York to be a "Special Focus Facility". The facility is inspected twice a year, rather than the standard annual inspection, and can only be removed from the special focus list by passing two consecutive surveys.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Winchester Centre for Health and Rehabilitation, a 183 bed nursing home facility located in Winchester, Kentucky, has been slapped with a Type A citation, which is the most serious citation Kentucky can assess for alleged abuse and neglect. The federal government has also said that it will terminate Medicare and Medicaid funding for the facility on February 7, 2009. Winchester Centre for Health and Rehabilitation is a one star facility, according to the new rating system instituted by The Centers for Medicare and Medicaid.

The facility refuses to elaborate on why it received the citation, saying only that "they had a problem with "medical errors" and that those problems had been corrected". Kindred Healthcare, the owner of Winchester Centre for Health and Rehabilitation, also refuses to comment.

Loss of federal funding from Medicare and Medicaid is serious and can result in closure of the facility. Losing funding from those sources means that the nursing home will no longer be certified to provide care for people receiving Medicare and Medicaid and patients living at the facility at the time of funding termination will be transferred to other certified facilities. Currently, it is unclear if Winchester Centre for Health and Rehabilitation will close. Other alternatives for the facility could be bringing in new upper management staff to run the facility and levying daily fines until identified problems are corrected.

Kathy Gannoe, the executive director of the Nursing Home Ombudsman Agency of the Bluegrass, said that her agency received 31 complaints in the past three months about Winchester Centre for Health and Rehabilitation. Eighty-six percent of those complaints have been satisfactorily resolved.

Provena St. Anne Center is a 179 bed nursing home facility located in Rockford, Illinois. The facility is rated as a two star facility in the new rating system instituted by Medicare.gov, indicating that it is a below average facility.

All nursing home facilities are required to advise a resident's family or legal representative when there is a change in condition or an injury. Provena St. Anne Center failed to do this in at least one instance with respect to a resident who sustained a skin tear that required first aid. After state intervention, nurses were in-serviced on the necessity of informing a resident's Power of Attorney timely when a resident sustains a skin tear requiring first aid intervention. The Director of Nursing was also forced to complete an audit of 10% of residents experiencing a skin tear that required first aid on a monthly basis.

All nursing home facilities must use the results of assessments to develop, review, and revise a resident's comprehensive plan of care. Provena St. Anne Center failed to develop a care plan that included objectives and interventions for a resident receiving peritoneal dialysis for the potential for complications arising from renal failure requiring hemodialysis. After state intervention, MDS coordinators and care plan coordinators were educated on assigning a comprehensive care plan for a peritoneal dialysis patients that includes approaches and interventions for peritoneal dialysis. Monthly reviews and audits must be conducted by facility staff and the Director of Nursing.

All nursing home facilities must provide services that meet the professional standards of quality. Provena St. Anne Center failed at least two of its residents in this respect when one resident was given medication after the one week stop date. Another resident received twice the ordered amount of medication on multiple days. Following state intervention, a mandatory in-service was conducted for all nurses regarding transcription, checking medication orders, stop dates for medications. Nurses were to check all transcriptions with another nurse to ensure accuracy. In another 2008 instance, a resident's central venous catheter was cut during a dressing change. The facility had only one rusty hemostat to use to stop the bleeding, so the line was tied off using a piece of string found at the nurses' station. The resident had to be supported by ambulance to a local hospital for replacement. After state intervention, the facility policy for dressing changes to PICC and central lines was changed and licensed staff was trained on the change in policy and the requirement to keep sharp objects away from the PICC and central lines.

All nursing home facilities are to provide pharmaceutical services that ensure accurate acquisition, receiving, dispensing, and administration of all drugs to meet the needs of its residents. Provena St. Anne Center failed at least one of its residents when she did not receive multiple medications on multiple consecutive days as the facility did not have the medications on hand. After state intervention, the nursing staff was in-serviced on giving medications without delay. Nurses were also in-serviced to track instances with pharmacy issues to identify opportunities for improvement.

Medication errors are unacceptable in any medical facility, much less a nursing home facility. Provena St. Anne Center failed to keep its residents free of significant medication errors and placed its residents in immediate jeopardy. A nurse administered Dilaudid instead of Morphine to a patient. Dilaudid is six times more potent than Morphine. The resident became unresponsive and had to be transported by ambulance to the hospital and was admitted with a diagnosis of altered mental status and hypercarbic respiratory failure. The administering nurse was not aware of the error until 44 hours after the event, when it was discovered during a morning drug count. The resident's physician was not notified of the error until eight days after the error. The hospital physician was not advised of the medication error either, thus delaying the appropriate treatment. After state intervention, the pharmacy consultant conducted a mandatory in-service on the 5 "R"s of medication administration - right route, right medication, right patient, right time, and right dose. The facility nursing staff was in-serviced on the facility's medication occurrence policy and focused on identification and reporting of errors as well as appropriate follow up. The in-service also convered the shift narcotic count policy. No nursing staff were allowed to work until they had received this in-service. It does not appear that the nurse involved was terminated.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Robyn L. Dunham, former payroll coordinator and bookkeeper for the Pines Heights Nursing Home in Vermont, has been charged with embezzling more than $8,000 from her former employer. Police were contacted in September 2008 by nursing home officials, who had discovered that Dunham had allegedly arranged for overpayments in her payroll check. Absent a plea agreement, she will likely face a trial on this matter.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

River Bluff Nursing Home is a 304 bed nursing home facility located in Rockford, Illinois. This facility scored two out of five stars in the new rating system implemented by The Centers for Medicare and Medicaid, which indicates a below average facility. River Bluff Nursing Home has exceeded the state deficiency average of eight deficiencies twice in the past three years. The facility had ten deficiencies in 2007 and eight deficiencies in 2006.

All nursing home facilities must conduct an initial assessment of a resident's needs and the assess the resident periodically to update the resident's care plan to meet growing needs. In one instance, a resident at risk for potential weight loss did not have a nutritional assessment in place and was steadily losing weight. This same resident also was at risk for edema. She was observed by state officials sitting in her wheelchair with swollen feet and ankles. After state intervention, the facility was forced to complete a nutritional assessment for the resident and complete an audit to ensure all other residents had nutritional assessments in place. The Dietary Supervisor also was required to report the results of the monthly chart reviews to the Quality Assurance Committee.

Proper care of nursing home residents is vital to prevent pressure sores. All nursing home facilities must ensure that a resident entering the facility wihtout pressure sores does not develop pressure sores and any residents with pressure sores are to receive the necessary treatment to promote healing and prevent infection. River Bluff Nursing Home staff failed to identify a resident's risk factors that contributed to the skin breakdown. The staff failed to identify open areas on a resident's sacral area. After state intervention, a new report log system was developed for CNAs to write down their observations and not rely on spoken word. Nursing staff was re-educated on skin care, observation, and reporting.

All nursing home facilities are required to ensure that the nursing home environment remains free of accident hazards and that each resident receives adequate supervision and assistance to prevent accidents. River Bluff Nursing Home failed at least one resident at risk for aspiration in this regard. This resident was on a general pureed diet with honey-thickened liquids and had the potential for aspiration and needed to be monitored for coughing and choking during oral intake. This resident also had an MRSA infection that could be spread. The resident was to eat in small bites and was to have supervision at meals. This resident was on isolation due to the MRSA infection and the possible spread of the infection to the resident's finger. During the state investigation, this resident was found in his room in bed eating breakfast alone. No staff members were present to assist. No staff members were present to ensure his safety. After state intervention, the resident's care plan was altered so that all of his meals could be taken in the dining room, where he could have supervision. The facility was forced to review all care plans for residents at risk of aspiration.

Nursing home facilities must store, prepare, and distribute food under sanitary conditions. River Bluff Nursing Home failed to have the sanitizer level in its three compartment sink at the required level for two separate observations. After state intervention, all dietary personnel were re-inserviced on performing test strip monitoring and procedure to notify supervisory personnel of non-compliance.

If specialized services, such as speech therapy, occupational therapy, mental health rehabilitative services, etc., are required in the resident's comprehensive plan of care, the facility must provide those services. River Bluff Nursing Home failed to provide yearly psychiatric exams, psychiatric rehabilitation programs, and a discharge plan for a resident with a severe mental illness. After state intervention, the facility was forced to conduct initial assessments and re-assessments annually of residents with diagnoses of severe mental illness to ascertain if the resident has a continuing need for physical care.

It is vital for all nursing home staff to wash their hands after each direct contact for which handwashing is indicated by professional practice. In fact, federal regulation 42 C.F.R. 483.65(b)(3) states that facility staff must wash their hands after direct resident contact for whcih handwashing is indicated by accepted professional practice. Certainly handwashing is indicated after cleaning up a resident's bowel movement. River Bluff Nursing Home staff failed to wash their hands as appropriate during incontinence care. For example, one CNA was observed cleaning a resident after a bowel movement. After cleaning the resident, the CNA placed a clean sheet on the bed and on the resident, then raised the resident's bed using the buttons on the side rail. Only then did she remove the gloves she had worn during the incontinence care. She subsequently removed her gloves and left the room without washing her hands. After state intervention, facility staff was re-educated regarding proper glove changing and hand sanitation. Random observances of hand sanittion and glove changing were ordered done by the infection control nurse for six weeks.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Tamara Smith

Tamara Smith sits in jail accused of stealing the identities of at least 43 nursing home residents. Smith accessed the personal information of several nursing residents through her former job of certified nursing assistant at Tara Nursing Home in Thunderbolt, Georgia. In fact, over half of her victims are current or former residents of the facility, who range in age from 60 to 100. The residents' personal information was used to buy computers, cell phones, and open credit card accounts.

A single family's complaint 15 months ago triggered the investigation. The number of victims continues to grow and more arrests are expected. It is the largest case of identity theft ever seen in Thunderbolt.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Edward Lee Marshall

Edward Lee Marshall, a restorative aide at Southtown Nursing in Bixby, Oklahoma, was arrested and jailed on complaints of making a lewd proposal and sexual battery. He was held on $27,000 bond until he was released Saturday, January 10, 2008.

Marshall was giving a bath to a blind and mentally and physically handicapped male resident. During the bath, Marshall was allegedly using his hand to perform a sex act on the male resident. Another employee saw the incident and reported it.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Woodcrest at Blakeford is a seventy bed nursing home facility located in Nashville, Tennessee. Woodcrest at Blakeford is a four star facility, which indicates an above average facility, according to the new rating system instituted by The Centers for Medicare and Medicaid. This facility has consistently kept their deficiency rate well below the state and national average for the past three years.

However, in at least one instance, Woodcrest at Blakeford failed to give professional services that met a professional standard of quality in 2007. The facility also failed to perform a new assessment after a major change in a resident's condition, failed to make sure that residents are safe from serious medication errors, and failed to make sure that the nursing home area is free from dangers that could cause accidents.

In both 2005 and 2006, Woodcrest at Blakeford failed to develop a complete are plan within seven days of a resident's admission or failed to check and update the existing care plan. In 2005, Woodcrest at Blakeford also failed to provide services to meet the needs and preferences of each resident, failed to keep each resident free from physical restraints, and failed to make sure that staff members washed their hands when needed.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

On December 18, 2008, Medicare launched its new quality rating system in which nursing homes and other care facilities are rated on a one to five star basis based on health inspections, staffing, and quality care measures. Nursing care issues concerned the storage of food and residents suffering from fevers, falls, or pressure sores.

Illinois nursing homes that scored an overall rating of "1" on the new system are: Eldercare of Alton, VIP Manor of Wood River, Edwardsville Nursing and Rehabilitation Center, Granite City Nursing and Rehabilitation, Eden Village Care Center, Willow Rose Rehabilitation and Health Care of Jerseyville, Maryville Manor of Maryville, Jerseyville Manor of Jerseyville, Alhambra Care Center of Alhambra, Helia Healthcare of Belleville, The Lincoln Home of Belleville, Calvin Johnson Care Center of Belleville, Pleasant Hill Health Care of Girard, and Stearns Nursing and Rehabilitation Center of Granite City.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Ten Nashville, Tennessee nursing homes have scored a one star rating, indicating a much below standard facility, according to the new rating system instituted by The Centers for Medicare and Medicaid. A one star rating is the worst rating a facility can receive according to the new rating system. The ten facilities with the worst ratings are:

Peachtree Center Nursing and Rehabilitation Center
Greenhills Health and Rehabilitation Center
Briley Nursing and Rehabilitation Center
Northside Health Care Center
Harpeth Terrace Convalescent Center
Donelson Place Care & Rehabilitation Center
Highland Manor Nursing & Rehab Center
Cumberland Manor Nursing Center
Bordeaux Long Term Care
Tennessee State Veterans Home

Inadequate staffing, fire safety, medication errors, and failure to investigate abuse were among some of the concerns cited.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Oak Park Place is an assisted living facility located in Dubuque, Iowa. The facility has come under fire from the Iowa Department of Inspections and Appeals recently following citations for insufficiencies concerning the care of its 42 residents, many of whom have serious health issues.

Recent inspections found several instances of failure to evaluate, deliver and follow up on resident care, problems with proper distribution of medications, and staffing issues. Some of the staffing issues involved not having appropriately trained nursing staff on duty. Inspectors also found evidence of records falsification "to the good of the administration".

One of the concerns involved an 84 year old resident with multiple medical problems, including Diabetes and coronary artery disease. A physician was to have been called if the resident's blood sugar level rose above 450 mg or below 60 mg. In September 2008, the resident's blood sugar rose above 450 mg at least eight times. There was evidence in the resident's chart that the physician was contacted sometimes, but not always. The facility failed to follow the physician's order.

Following a March 2008 inspection, the facility received its first fine in the amount of $2,500. The facility failed to make necessary corrections by July 2008 and was slapped with an additional $4,000 fine and a conditional certificate. A conditional certificate is a step below a license revocation. Recently, the facility was hit with a $10,000 civil penalty and the conditional certificate was continued until the program was in compliance or until August 25, 2009. If the facility fails to be in compliance by that date, it can lose its license. The facility can lose its license prior to that date if more violations are uncovered. In addition to the conditional certificate, the facility is not allowed any new admissions until the restriction or conditional certificate is removed. The facility is also required to submit monthly updates on medication reviews and nurse delegation training forms, and life safety training forms. In the past eighteen months, the facility has received twelve conditional certificates.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please call us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Joyce Stanley

We discussed Joyce Stanley and Etowah Health Care Center in previous blog entries. Stanley pled guilty on January 9, 2009 to assaulting a blind resident. Stanley hit a seventy-four year old blind woman with a clipboard and an incontinence pad. Ms. Stanley also slapped the victim and pulled her hair. She was sentenced to one year in jail, although she only has to serve thirty days in jail. The rest of her sentence will be served as probation. She also owes over $500 in fines.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Henrietta Sprual, a care worker at Arden Court nursing home in Pennsylvania, failed to appear in Court on January 7, 2009 for sentencing for a brutal assault on an elderly nursing home resident. Spraul struck an 87 year-old Alzheimer's patient with a belt six to eight times in December 2007. The bruises were so clear that the imprint of the belt buckle was visible. Spraul admitted that she intentionally beat the resident.

When Spraul ended her shift on December 8, 2007, she advised her supervisor that she found scratches on the man's hands and face at the beginning of her shift and wrote a report listing her observations. When two other care workers began their shifts, the found multiple bruises on the man on his arm, elbow, shoulder, knee, and thigh. They reported the bruising to their supervisor and advised that it appeared as if a belt buckled caused the bruising.

When Spraul returned to work the next night, she was questioned again about her observations and she alleged that she only noticed scratches. When a third interview was conducted using photographs of the injuries and the belt that was believed to have been used, Spraul claimed the resident found the belt at the nurse's station and began swinging it and "was out of control". She alleged that he was swinging the belt around and striking himself with it. A forensic pathologist found that the injuries were not self-inflicted and apparent force was used to inflict them.

She had pled guilty in October 2008 to simple assault, reckless endangerment, possession of an instrument of crime, and false statements.

Roxie Luff

Roxie Luff pled guilty to five drug-related offenses resulting from the theft of residents' medications at The Otterbein Home in Lebanon, Ohio. Luff was fined and placed under five years probation. She was also prohibited from working as a nurse for three years.

Luff falsified charts to show that she had administered Hydrocodone and Oxycodone to her patients but took the drugs herself. Residents underwent testing that proved that they had not taken the drugs that Luff was accused of stealing.

Sr. Mary Daniel

We discussed the tragic injury and death of Sister Mary Daniel in our previous blog. Sr. Mary was found on the floor in her room on August 31 bleeding profusely after a freestanding closet unit fell on her. She died on September 7 from a fractured skull.

Summit Park Hospital and Nursing Care Center has been fined $10,000 by the State of New York for failing to secure the 200 pound freestanding closet to the wall. The facility must also pay $2,000 for failing to take action for two similar previous incidents.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Annie Bell Scarboro was a known "wanderer" at Five Oaks Manor nursing home in Concord, North Carolina. She was not injured on May 22, 2008 when she escaped the facility and was found by the dietary staff on a ramp in the parking lot. Ms. Scarboro, an Alzheimer's patient, left the facility undetected by a back kitchen door. The staff took precautions by putting a "wander guard" bracelet on her and facility staff was to check her every 15 minutes. They also limited her wandering to areas where she could be monitored.

On December 18, 2008, Ms. Scarboro was seen walking around using her "merry walker" around 8:45 p.m., but by 9:00 p.m. no one could find her. The entire facility was searched, but Ms. Scarboro could not be found. At 9:20 p.m., a nursing assistant finally located her. She had fallen four feet from the loading dock outside the kitchen door and was lying on the ground with her "merry walker" was on top of her. She had a head laceration and "blood was running everywhere", but she was breathing and had a pulse. She was taken to the Carolinas Medical Center and later died.

How did Ms. Scarboro make it through three sets of doors into the kitchen area and onto an unlit loading dock undetected? Where were her caregivers?

The Department of Health and Human Services found that Five Oaks "failed to prevent a cognitively impaired resident from accessing the loading dock, resulting in a fall". Their recommendation was that the facility be fined $10,000 per day for a five-day period from December 18 through December 22, when the facility repaired deficiencies. Those deficiencies included a repairing a broken lock to the loading dock door, installing an alarm at the door, replacing bulbs to light the loading dock, and building a fence along the loading dock.

Five Oaks Manor is a one star nursing home, according to the new rating system instituted by The Centers for Medicare and Medicaid, which indicates a below average facility.

The Terry Law Firm is experienced in handling nursing home cases of abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Rosewood Care Center of Rockwood is a ninety-four bed nursing home facility located in Rockford, Illinois. The facility received a two out of five star rating from The Centers for Medicare and Medicaid, which indicates a below average facility.

Residents of nursing home facilities are allowed visitation with any visitors of their choosing at established visiting hours. A resident of Rosewood Care Center of Rockford was denied visitation with the former Director of Nursing of the facility. There were no orders in the resident's file that she could not visit with the former employee. When asked, the Administrator stated that it was facility policy not to allow former employees in the building. After the state survey, the Administrator was re-inserviced on the facility policy regarding visitation and took immediate steps to allow the resident to visit with the former Director of Nursing.

Nursing home facilities must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Rosewood Care Center of Rockford created an immediate jeopardy situation for its residents when facility staff failed to assess and provide timely care for a resident suffering from abdominal pain after a CNA reported the symptoms to a nurse. The patient was in excruciating pain for nine hours before being sent to the hospital for evaluation and treatment. The resident died at the hospital from sepsis and the gastrointestinal bleed. The nurse in charge that evening did not document any treatment for the resident, even though she said that she gave the resident a pain pill. After the state survey, the facility was required to develop and implement written policies and procedures that prohibit mistreatment and neglect of residents. Facility staff was re-inserviced on the facility policy regarding timely assessments and reporting changes in residents' conditions. This includes response to CNA reports on residents and following policies.

All nursing home residents are entitled to care and services that attain or maintain the highest practical physical and mental well-being and which follows the resident's care plan and assessment. Rosewood Care Center of Rockford failed two of its residents in this regard. A resident was admitted to the facility following a right total knee arthroplasty. On the date of admission, facility staff did not perform an assessment of the wound and the wound was not assessed. In fact, no one assessed the wound for the next three days. Upon the resident's complaint on the fourth day of admission, the wound was finally observed. Redness was noted around the dressing, yet no one further assessed the wound. Five days after admission, the leg was observed to be red, swollen, and warm and painful to touch. The resident's foot was so swollen and tender that she could not move it at all. The resident was transferred to the hospital and admitted with cellulitis of the right knee. Another resident had a fluid restriction order for 1500cc. This resident did not have a meal intake sheet because his fluid restriction was monitored due to a cardiac condition. The resident's Fluid Plan showed that he was to be offered 900cc of fluid daily from the dietary department and 600cc of fluid with his medications. The resident's intake and output report sheet indicated that the resident was receiving less than 1500cc of fluid daily. The resident assessment noted that the resident's urine was amber colored and he voided little that day, yet his physician was not notified of this critical issue. The resident was found dead the following day. After state intervention, the facility nursing staff was re-inserviced on facility policy on charting in resident records. The facility Director of Nursing is required to monitor compliance by auditing at least one chart per week to ensure compliance and that resident's are being correctly assessed and changes in condition are being recorded and interventions implemented. In another instance,some residents had changes in condition that led to emergency transfers and the facility failed to notify the their physicians immediately concerning that change. Following the state survey, the facility re-inserviced the nursing staff on facility policy regarding reporting and documenting changes in residents' conditions. The Director of Nursing is required to monitor for compliance through resident spot checks for changes in condition at least once a week.

Every nursing home resident has the right to prompt efforts by the facility to resolve grievances that the resident might have, including those that concern the behavior of other residents. Rosewood Care Center of Rockwood residents were having problems getting facility staff to timely respond to call lights on many occasions in multiple months. One resident complained of call lights being on for thirty minutes while waiting for assistance and other residents complained of lights not being answered promptly. In one instance, when a call light was on, a CNA came in and shut it off and said she would be right back and never came back. In response to the state survey, the facility direct care staff was re-inserviced on facility policy regarding answering call lights in a timely manner. The facility instituted a call light audit program. The facility Administrator and Director of Nursing is to monitor for compliance.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

River Park Health Care Center is a 58 bed nursing home facility located in Nashville, Tennessee. The facility received two out of five stars, according to the new rating system implemented by The Centers for Medicare and Medicaid, which indicates a below average facility. While the average number of health deficiencies for the State of Tennessee is seven, this nursing home has consistently attained a higher deficiency rate for the past two years. For the 2007 complaint reporting period, this facility had fourteen deficiencies and for the 2008 complaint reporting period, that number increased to deficiencies.

Nursing homes are supposed to hire only people who have no legal history of abusing, neglecting, or mistreating residents. They are legally required to report and investigate any acts or reports of abuse, neglect, or mistreatment of residents. Additionally, facilities are to write and use policies that forbid mistreatment, neglect, and abuse of residents and theft of residents' property. In 2008, River Park Health Care Center placed its residents in immediate jeopardy when it failed to adhere to these policies.

Nursing homes are required to provide each resident care and services to get or keep the highest possible quality of life possible. These services are to meet a professional standard of quality. River Park Health Care Center failed its residents in 2007 and 2008 when it did not provide services that met both of these standards. Additionally, the facility failed to provide the correct treatment and services to residents who have mental or social problems adjusting and provide proper treatment to prevent new bed sores or heal existing bed sores. The facility also failed to make sure that residents who cannot care for themselves received help with activities of daily life.

Nursing homes are to develop a complete care plan for each resident within seven days of admission. The care plan should be updated periodically to allow for changes in the resident's condition. River Park Health Care Center caused actual harm to a resident when it failed to adhere to this policy. Additionally, the facility violated resident rights when it did not allow residents to easily see the results of the facility's most recent survey, when it did not provide services to meet the needs and preferences of each resident, and when it failed to inform each resident who was entitled to Medicaid benefits, about which items and services Medicaid covers and which one the resident has to pay for, and how to apply for Medicaid. Resident rights were further violated when the facility failed to keep each resident's personal and medical records confidential and failed to provide proof that all residents' personal money deposited with the facility was secure.

Good nutrition is vital to a nursing home resident. Nursing home facilities are required to store, cook, and distribute food in a safe and clean way. River Park Health Care Center violated this right in 2007 and 2008 and caused actual harm to a resident in 2008.

River Park Health Care Center is required to have drugs and other similar products available which are needed every day and distribute them properly. River Park Health Care Center failed to adhere to this policy in both 2007 and 2008.

All nursing home facilities are required to provide the necessary housekeeping and maintenance to ensure the facility runs smoothly. The facility nursing home area should be free of dangers and accidents and the surroundings should be clean and safe. River Park Health Care Center failed its residents in these respects in both 2007 and 2008 and actually placed its residents in immediate jeopardy by failing to ensure the facility was free from dangers that cause accidents. This facility's staff members were cited in both 2007 and 2008 for failing to wash their hands when needed. The facility also failed to have a program to keep infection from spreading.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Lakeshore Wedgewood is a twenty-six bed facility located in Nashville, Tennessee. The facility received three out of five stars, according to the new rating system instituted by The Centers for Medicare and Medicaid, which is an average rating.

All nursing homes are required to provide professional services that meet a professional standard of quality. According to the governement surveys, Lakeshore Wedgewood failed its residents in this regard in 2007 and 2008.

Nursing homes are required to develop a complete care plan within seven days of admission and that care plan is to be checked and updated periodically. New assessments are also to be done after any major change in a resident's physical or mental health. Lakeshore Wedgewood was cited in both 2007 and 2008 for failing its residents in this regard. In at least one instance, the facility failed to immediately contact a resident's physician or legal representative regarding a major change in the resident's condition.

Some nursing homes provide in-house pharmacy services for its residents. It is vital that nursing home residents receive the appropriate medications at appropriate times. Lakeshore Wedgewood failed to keep its rate of medication errors to less than 5% in 2006. Simply put, this means that 5% of the time, Lakewood Wedgewood's residents were given the wrong drug, the wrong drug dosage, or that medications were given at an incorrect time. The facility also failed to have drugs available which are needed every day and in emergencies and to distribute them properly.

Diet and nutrition are vital to a nursing home resident's health. Nursing homes are to provide store, cook, and distribute food in a safe, clean way. Lakeshore Wedgewood failed to do this at some point in 2007 and 2008. Additionally, in 2008, the facility failed to make sure that the attending physician ordered special diets and ensure that the food prepared is nutritional, appetizing, attractive and tasty, well-cooked, and at the right temperature.

The nursing home environment should be kept free of dangers that could cause accidents. The facility should provide the necessary maintenance and housekeeping to keep the facility running smoothly. The facility should also get rid of garbage properly and have a program to keep infection from spreading. Lakeshore Wedgewood received citations for each of these areas in 2006.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please feel free to contact us at 1 (888) 317-2525 or at www.nursing home justice.com.

Currently, Tennessee is one of sixteen states that does not limit the amount of damages plaintiffs can be awarded in court with a favorable judgment. Tennessee nursing home officials want to change this and support a bill introduced last year by State Senator Jim Tracy (R) and former Representative Randy Rinks (D). The bill proposed that non-economic damages, such as awards for pain and suffering, be limited to $300,000 for plaintiffs filing lawsuits against nursing homes. The bill is expected to come up in the 2009 legislative session.

Gerald Coggin, Senior Vice President of Corporate Relations for National HealthCare Corp., a nursing home operator, says that nursing homes are "delivering resources away from care to constantly defending themselves against frivolous lawsuits". Interestingly, NHC was the subject for a $34 miillion judgment against its McMinnville, Tennessee facility.

Frivolous lawsuits? Tennessee nursing homes ranked as the third worst nursing homes in the country, according to The Centers for Medicare and Medicaid. Of the state's 319 nursing homes, only 22 received a top rating of five stars and 111, or approximately 1/3 of the state's nursing homes, received one star, the worst rating a facility can receive.

Nursing home owners only stand to profit from the bill introduced by Senator Tracy and Representative Rinks. Limiting liability is only going to allow the nursing home owners to continue on their current path of substandard care and allow them a cheaper payoff for any injuries or death residents may suffer due to the substandard care, allowing the nursing homes to continue to increase their profits.

Most people view nursing homes as a place to care for a resident's physical needs and provide safety. Often, the ailments of nursing home residents cause mental or emotional issues and nursing home social workers vital to nursing home residents to care for those needs. The social workers are to advocate for residents and monitor them for emotional issues, stress, and depression. Nursing home social workers are to help residents and their families transition between the facility and the hospital or hospice and assist with locating necessary resources for nursing home residents.

Interestingly, even with such important responsibility for residents, nursing home social workers are not held to any standardized qualifications. The federal standards for nursing home social workers are very low and state laws are inconsistent.

According to a recent study from the University of Iowa, only half of 1,071 nursing home social workers have a degree in social work and 20% do not have a four year degree. Two-thirds of the social workers surveyed do not belong to a professional organization that keeps them up to date on current nursing home social work issues, such as elder suicide and physical, emotional or financial abuse, and only 38% are licensed social workers.

Federal law requires homes with more than 120 beds to employ a full-time social worker. Most facilities do employ one, but devoting an appropriate amount of time to any one individual is nearly impossible. Federal guidelines indicate that one social worker can handle up to 120 residents. However, when asked, the majority of the survey panel indicated that fewer than 60 residents could be managed by one social worker.

Ten states do not address nursing home social worker qualifications and seven state codes do not comply with federal regulations. Twenty-one states require a social work degree and most others require a four year degree - but not necessarily in social work. Anyone with a bachelor's degree in any human service field and one year of supervised experience in the field is considered qualified. There are glaring loopholes in Colorado and Indiana. In Colorado, for-profit nursing homes in rural areas do not have to hire a qualified social worker if they advertise for a week in a local paper are unable to fill the position. In Indiana, social services can be provided by a member of the clergy who completes a 48 hour course and consults with a social worker.

Given the importance of social workers in the nursing home setting, one wonders if this is not an area that should be examined more closely.

Linda Shaw

On July 16, 2008, Linda Shaw was the sole caregiver for overnight care shift for sixteen residents of Personal Care II, an assisted living facility located in Bradenton, Florida. She was scheduled to work from 7:00 p.m. to 7:00 a.m. A maid at the facility told investigators that Shaw left the center to "go to the beach" and never returned. A facility resident advised that Shaw would frequently leave the facility when scheduled to work. While Shaw was gone, a 47 year old disabled woman suffered a heat stroke and seizures in her room. Her roommate found her on the floor unresponsive with her arms flailing above her head. The roommate called 911 and the resident was taken to the hospital in critical condition. Doctors determined that the resident's temperature was 106 degrees. The air-conditioning in the facility had been off for several days and the temperature in the resident's room was extremely hot.

Shaw said she left the facility at 7:30 p.m. to go home and get her medication and admitted she did not return.

Shaw was arrested and faces charges of neglect of a disabled adult. If convicted, Shaw faces up to five years in prison. Court records allegedly show that Shaw has a criminal history with a 1991 conviction for retail theft and a 1994 conviction for assault and battery.

Rockford Healthcare & Rehab Center is a 97 bed nursing home facility located in Rockford, Illinois. The facility is rated as a one-star facility according to the new rating system instituted by The Centers for Medicare and Medicaid, which indicates a below-average facility in 2008.

Nursing home facilities are required by law to notify a resident's physician or legal representative of any change in a resident's condition or if an accident or injury has occurred. Rockford Healthcare and Rehab Center failed at least one of its residents in this respect in 2008. A resident had a Stage II pressure sore on the coccyx that was discovered on August 25, 2008. There were no treatment orders in the resident's file for the pressure sore. On September 8, 2008, the resident was observed lying on a soiled incontinence pad with the wound uncovered and no treatment in place. The resident's family had not been notified of the wound. As a result of the state investigation, the facility notified both the resident's physician and family on September 8, 2008. The facilty re-inserviced nurses and counseled nurse who failed to notify the resident's physician on both doctor and family notification procedures. Nurse charting, new orders, and resident changes are to reviewed Monday through Friday for three months.

All residents are entitled to be free from verbal, physical, sexual, or mental abuse, punishment, or involuntary seclusion. Rockford Healthcare and Rehab Center failed to prevent the abuse and injury of an impaired resident by a roommate with a history of physical aggression. The resident with a history of physical aggression broke off a control lever from a recliner and was hitting the resident on the head with the lever repetitively. The resident, who was on blood thinners, complained of head and hip pain and suffered multiple lacerations. As a result of the state investigation, the facility re-inserviced staff on abuse reporting policy and procedure and initiated a new admission acceptance form. The facility will review all available information on resident behavior before admission. Resident Care Plans were reviewed and updated to include abuse or potential to be abused. Resident behaviors must also be reviewed randomly for three months.

Rockford Healthcare and Rehab Center is legally obligated to develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents. The facility failed its residents by not providing nursing care to prevent physical harm and failing to follow facility policies and procedures. For example, a pressure sore was discovered on a resident at the end of August 2008. No treatment orders were in place in August or September 2008 for the pressure sore. Additionally, the same resident did not receive nutritional support to meet his physical needs. Rockford Healthcare and Rehab Center immediately assessed the affected resident and notified the resident's physician. Treatment was initiated immediately. The facility also instituted a policy that within 24 hours of admissions all new admissions will have their skin checked and tube feeders will be assessed. Facility staff were inserviced on skin assessment, physician notification, treatment of skin issues. and tube feed requirements. Quality Assurance will monitor all skin areas weekly and the Clinical Administrator will review all tube-fed residents monthly to ensure adequate nutrition.

Nursing home facilities are legally obligated not to employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law or have a finding entered into the state nurse aide registry concerning abuse, mistreatment, or neglect. Rockford Healthcare & Rehab Center failed its residents when it failed to investigate bruises on a resident's arms and a foot fracture of unknown origin. The facility also failed to fully investigate a resident's allegations of being slapped and a report of staff stepping on her toes. The facility failed to interview the charge nurse and remove the accused staff from resident care until the investigation was completed. After the state intervened, the facility had to re-inservice staff on reporting bruises of unknown origin and abuse allegations to the administrator immediately so investigations could be completed. The facility will investigate thoroughly allegations of abuse.

Rockford Healthcare & Rehab Center residents have a right to receive services in the facility with reasonable accommodations of needs or preferences. The facility failed a new resident in this respect when it it failed to provide the new resident with a wheelchair appropriate for her needs. The resident was found sitting in her wheelchair, crying, and asking to lay down. She was slouched down in the chair and holding on to the arm rests for support. There were no foot rests on the wheelchair and the wheelchair was too small for her body. In fact, it was so small that the resident's thighs were indented by the sides of the wheelchair and the wheelchair armrests were pressing into the resident's waistline. When questioned by the state, the facility immediately removed the resident from the wheelchair and placed her into a new wheelchair that was better suited for her needs. All facility residents were reassessed for wheelchair and appliance appropriateness. Nurses were inserviced so that the problem would not occur again.

Care Plans are vital to a nursing home resident's well-being. Without an accurate Care Plan, the resident will not be able to achieve or maintain the highest practicable physical, mental, and psychosocial well-being. In one instance, an unsupervised resident performed "surgery" using a nail clippers on a foot callus to relieve the pressure on his foot. After this was discovered, the facility Clinical Administrator met with the resident and educated him on the risks and harm that occur from performing "surgery" on his foot. The facility has initiated a new behavior program for the resident.

All care received at Rockford Healthcare & Rehab Center must meet professional standards of quality. An insulin dependent resident was to have his blood sugar checked every morning at 6:00 a.m. The facility had eleven glucose monitoring errors in seventeen days on the same resident where the glucose was checked at the wrong time or was not checked at all. As a result of state involvement, the facility contacted the resident's physician and clarified the order. Facility licensed nurses were inserviced on blood glucose and medication errors.

Pressure sores can be a serious problem for bed-bound nursing home residents if they are unmonitored and not properly treated. If the resident's skin is not properly cared for, infection from the pressure sore can result in serious illness and possibly death. Like all nursing homes, Rockford Healthcare and Rehab Center is required to ensure that a resident entering the facility without pressure sores will not develop pressure sores. A resident with pressure sores is to receive the necessary treatment to promote healing, prevent infection, and prevent new sores from developing. The facility failed several residents when it failed to routinely assess resident skin conditions, identify new open areas, document skin conditions, and obtain treatment orders. Moreover, the facility failed to prevent a resident at low risk for skin breakdown from developing deep tissue injury and further skin breakdown. After the state survey, Rockford Healthcare and Rehab Center counseled nurses who failed to assess and follow up on residents affected with pressure sores. All residents were assessed and pressure relieving devices were provided as needed. The facility also re-inserviced all CNAs and nursing staff on pressure ulcer prevention and protocol.

Rockford Healthcare and Rehab Center is required to ensure that the environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance to prevent accidents. The facility failed in this respect when staff failed to ensure that a fall-risk resident's chair alarm was turned on and operational. The resident fell forward in his wheelchair and he landed face first on the floor. The facility assessed the resident's chair alarm and found it to be faulty. The alarm was replaced. All other facility alarms were checked for working order and worn out batteries were replaced and/or replaced faulty alarms. After this resident's injury, facility staff were in-serviced on appropriate alarm usage.

Rockford Healthcare and Rehab Center must ensure that residents receive appropriate nutritional support if being tube-fed. The facility failed to ensure that its resident received the appropriate caloric intake through tube feeding. Rockford Healthcare and Rehab Center was forced to rectify this problem through a new care plan and the facility in-serviced its nurses on tube feed requirements.

The Terry Law Firm is experienced in nursing home cases involving abuse and/or neglect. Please contact us at (888) 317-2525 or through our website at www.nursinghomejustice.com.

Florence Ko and Maria Tseu

Florence Ko had no idea she was being evicted from Nu'uanu Hale, a Honolulu nursing home, or why. On Decemer 17, 2008 - only one week before Christmas, she returned from physical therapy and found her personal belongings piled on a gurney and people cleaning her room. Ko, who is 81 years old and confined to a wheelchair due to polio-related ailments, had nowhere to go. The nursing home apparently did not care - they dropped Ms. Ko off at Straub Clinic & Hospital's Emergency Room wearing only a hospital gown and left. She had less than $3 in her purse and had only a cell phone - without a charger. Her belongings were placed under a tarp outside the facility, where members of Ms. Ko's church retrieved them later.

Ms. Ko, who had been a resident of the facility since July 2007, was caught in the middle of a financial tug-of-war between the facility and Medicaid. While she received a regular income from Social Security and an annuity, the amount was not enough to cover her nursing home costs. Family members tried to get Medicaid to cover her long-term bills, but her application had been rejected twice. Her application for Medicaid was affected by her former home, which had been demolished in 2007. The property, valued at more than $1 million, remains in a family trust, but is deeded to Ms. Ko's daughter. Ms. Ko thought her financial situation was going to be resolved, but the caseworker assigned to her recently was laid off and apparently she fell through the bureaucratic cracks.

The facility alleges that Ms. Ko's family stopped paying the bill. The facility Administrator, Gayle Lau, said the facility was cooperating with investigators, but cautioned the Honolulu Advertiser about writing a story about the incident stating "It is one-sided at this point."

The Department of Human Services called the drop-off inappropriate and was referring the matter to the Department of Health, which is the licensing agency for Hawaiian nursing homes. Nu'uanu Hale received one out of five stars on the new rating system instituted by The Centers for Medicare and Medicaid, which is the poorest rating available.

Elderly residents in Ramsey County, Minnesota can rest easier now that Ramsey County has created its Elder Abuse Unit. The Elder Abuse Unit, which has been formed to prosecute people targeting the elderly, will consist of two attorneys in the County Attorney's Office. These attorneys will review all elder abuse cases for charging decisions and five attorneys will handle the trials. The Elder Abuse Unit will also assign victim/witness advocates to all cases and will work with adult protection departments, elder advocacy organizations, and victim organizations.

The Elder Abuse Unit will utilize existing resources in the Ramsey County Attorney's Office and will require no new funding.

Lakeshore Heartland is a 66 bed nursing home facility located in Nashville, Tennessee. This nursing home is rated as a three-star facility, according to The Centers for Medicare and Medicaid, which is considered average. The average number of health deficiencies in Tennessee is seven. Lakeshore Heartland has consistently averaged more than the average number of health deficiencies over the past three years. In 2005, the facility had 12 deficiencies. In 2006, the facility's deficiencies numbered 19 and for 2007, the facility had nine deficiencies.

All nursing home residents are to be kept free of physical restraints unless needed for medical treatment. Lakeshore Heartland failed its residents in this regard.

Nursing home facilities are to provide professional services that meet a professional standard of quality and follow each resident's Care Plan. Lakeshore Heartland has repeatedly failed to provide professional services meeting a professional standard of quality over the past three years. The facility has also failed to provide the proper treatment to prevent new bed sores and help heal existing bed sores on more than one occasion. In one instance, the State determined that the facility's failures had caused actual harm to a resident. The facility also failed to provide proper treatment to residents with feeding tubes. Lakeshore Heartland did not use a registered nurse for at least eight hours a day, seven days a week as required by federal law and failed to have enough nurses to care for every resident in a way that maximizes their well-being.

All facilities are required by law to develop a complete Care Plan within seven days of a resident's admission that meets each individual resident's needs. The Care Plan is to be developed with the care team and it should be updated frequently to address the changes in the resident's health. In the past two years, Lakeshore Heartland failed to adhere to this standard and also failed to do a new assessment after a major change in the resident's health.

Changes in any resident's health are to be reported to the resident, the resident's physician, legal representative, or family in a timely manner. The facility failed to do so and violated at least one resident's rights. The facility also failed to provide care in such a way that it builds each resident's dignity and self-respect.

Food in every nursing home is to be cooked, distributed, and stored in a safe and clean way. According to these state surveys, Lakeshore Heartland failed their residents in this respect.

It is imperative that the rate of medication errors in nursing home facilities is kept below 5%. Failure to accurately distribute medication can result in serious injury or death. Over the past three years, Lakeshore Heartland has consistently failed to meet this standard.

Nursing home facilities should be free from dangers that cause accidents. Lakeshore Heartland has failed its residents two out of the past three years on this standard. It has also failed to keep all essential equipment working safely and provide needed housekeeping and maintenance.

The New York State Department of Health is investigating a possible sexual assault at Shore Winds Nursing Home in Rochester, New York. The complaint came in right before Christmas and alleged that a nursing home worker had sexual contact with a resident. The New York State Department of Health found that the claim was serious enough to warrant further investigation.

The nursing home appears to be cooperating with the investigation. Over the last three years, Shore Winds allegedly has had 46 complaint investigations and been cited four times. It is rated as a two star facility under the new system instituted by The Centers for Medicaire and Medicaid.

The Terry Law Firm is experienced in handling nursing home sexual abuse or assault cases. For more information, call us directly at 1 (888) 317-2525 or visit our website at www.nursinghomejustice.com

Greenhills Health and Rehabilitation Center is a 150 bed nursing home facility located in Nashville, Tennessee. This facility is rated as a one-star nursing home according to the new system instituted by the The Centers for Medicare and Medicaid, which is below average. While the average number of health deficiencies for the State of Tennessee is seven, this nursing home has consistently attained a higher and progressively worse deficiency rate. For the 2005 complaint reporting period, this facility had eighteen deficiencies. For the 2007 complaint reporting period, there were nineteen deficiencies and for the 2008 complaint reporting period, there were thirty-nine deficiencies.

All nursing home facilities are required by law not to hire people who have a history of abusing, neglecting, or mistreating residents and to report and investigate any acts or reports of abuse, neglect, or mistreatment. Greenhills Health and Rehabilitation Center failed its residents in this regard and actually caused its residents actual harm in the 2008 complaint reporting period.

Federal law requires that each resident at a nursing home facility must receive the necessary care and services to attain the highest well-being possible. These services must be provided in a professional manner and must follow each resident’s written care plan. This facility failed its residents in this regard and placed them in immediate jeopardy. Federal regulations define Immediate Jeopardy as a situation in which the [nursing home] provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. Greenhills Health and Rehabilitation Center did not have enough nurses to care for every resident in an appropriate manner, did not ensure that residents unable to care for themselves received help with activities of daily living, and did not provide proper treatment to residents with feeding tubes to prevent problems. Residents were actually harmed or placed in immediate jeopardy when facility staff did not provide enough fluids to residents to keep them healthy and prevent dehydration, did not provide proper care for bed sores, and did not ensure that each resident entering the facility without a catheter did not receive one. The facility also failed to provide the appropriate treatment and services to residents who have mental or social problems adjusting.

All nursing home residents should have an accurate Care Plan in place and the Care Plan should be reviewed and revised regularly and upon a change in condition Obviously, without an accurate Care Plan, the facility is unable to meet the medical, nursing, and mental needs of its residents. Greenhills Health and Rehabilitation failed its residents in this respect when it consistently failed to develop a Care Plan within seven days of a resident’s admission with a care team or failed to update and check the Care Plan. The facility also failed to make sure all assessments were performed by a registered nurse and are signed by the person completing them.

All residents should be treated with respect and dignity. Greenhills Health and Rehabilitation failed to protect resident rights when it consistently failed to notify the appropriate individual of a resident injury or change in condition and provide care and services that met the needs and preferences of each resident and provided the care and services in such a way that the resident’s dignity and self-respect was maintained. This facility also failed to ensure that its residents were well nourished and that the residents’ food was stored, cooked, and distributed in a clean and safe way.

Greenhills Health and Rehabilitation failed its residents when it did not ensure that the rate of medication errors did not exceed 5% and when it did not ensure that residents taking medications were not given too many doses for too long or did not stop the medications when adverse effects appeared.

All nursing home residents have the right to a clean and safe facility. Greenhills Health and Rehabilitation has consistently failed to ensure that the nursing home area is free of dangers that cause accidents. It also failed to provide necessary housekeeping and maintenance, have enough backup water supply, and move, clean and store all linens in such a way that it prevented infection.

Greenhills Health and Rehabilitation has also been cited for administrative violations over the past two years. The facility has failed to be administered in such a way that the highest possible levels of well-being for each resident are achieved, failed to keep accurate medical records and complete dated lab records in resident files, ensure that nurse aides have the skills to care for residents, and choose a doctor to be the medical director. The facility also failed to set up and keep a group of people to review and ensure quality.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. For more information, call us directly at 1 (888) 317-2525 or visit our website at www.nursinghomejustice.com.

Seijdra Eribo

Asher Kennon hasn't been able to speak since he was a small boy. Asher, now 27, suffers from severe autism. It appears his autism made him an easy target for abuse by one who was to care for him.

In October 2008, Asher suffered second and third degree burns on his neck and arm while staying at a group home in Fort Worth, Texas. The home is run by Medical Case Management and Seijdra Eribo is the Director. Sadly, when Ashton's parents uncovered the abuse, they could not get anyone to tell them what had happened to their son. They called police.

Police investigated the matter and eventually Eribo, the staff director, admitted to burning Asher with hot water. She provided no reason for her cruelty. Eribo was arrested on January 28, 2009, on suspicion of felony injury of a disabled person, causing severe bodily injury. Interestingly, she was fired from the facility for failing to fully cooperate with the investigation - not for abusing a resident!

Forest View Rehabilitation Center in Durham, North Carolina closed in November 2008 following investigations in August and September 2008 that revealed very serious hygiene, health, and safety violations.

In one instance, fire ants were found in a resident's room and approximately 150 fire ants were crawling on the resident's body, causing eight inch welts from his arm pit to his waist. The fire ants had built a mound outside by a dumpster and an ant trail led from the dumpster, past a smoking area, into the resident's room.

At least two mentally impaired residents were sexually assaulted by other "alert and oriented" residents, one of whom carried a sexually transmitted disease. One of the aggressors in the incident was transferred to another facility. The physician of the other aggressor wrote, "Because he is a danger to an incompetent female resident and other patients we can no longer safely care for him in a safe environment for all of our residents." Yet, the administrator of Forest View, John Walder, blamed the victim in this incident alleging that the victim, who had been diagnosed with psychosis and other mental disabilities and often acted out sexually, initiated the sex.

Many of the deficiencies cited by the State occurred because nursing home staff did not follow designated procedures, but the failure began at the top of the hierarchy. The Director of Nursing stated that she was "unaware" of many of the major violations at the facility. In one instance, she allegedly stated she didn't know there were no doctor's orders for catheters for several residents. In another instance, after investigators discovered that there had been no registered nurse on duty for more than a day (law requires a registered nurse on duty for at least eight consecutive hours daily), the Director of Nursing was quoted as saying "she did not think about registered nurse coverage for the day".

Other serious violations uncovered at the facility were repeated falls by residents, residents with painful pressure sores not given any painkillers to alleviate their discomfort, and urinary tract infections contracted from dirty catheters - in at least one instance, the catheter was washed with the same cloth used to wipe feces from a person's rectum.

Amazingly, there was only one instance of documented disciplinary action - on a van driver. The driver was suspended and formally disciplined after a resident using a power wheelchair tipped over in his wheelchair and was lodged against a window in the moving van after the chair had not been properly strapped down. The facility's transport service was discontinued.

The facility was home to approximately 100 residents with a variety of mental and physical disabilities ranging from Alzheimer's disease to kidney disease to multiple sclerosis. The residents were transferred to other facilities for care.

Forest View was owned by Durham Manor, L.L.C. but managed by Epic Group. The building will be sold.

To view various survey reports on this nursing home, go to:

April 2, 2008 Survey, Part I
April 2, 2008 Survey, Part II
May 8, 2008 Survey

Fairview Nursing Plaza is a 213 bed nursing home facility located in Rockford, Illinois. This facility is rated as a one-star nursing home according to the new system instituted by The Centers for Medicare and Medicaid, which suggests a below average facility. While the average number of health deficiencies for the State of Illinois is eight, this nursing home has consistently attained a higher deficiency rate. For the 2006 complaint reporting period, this facility had ten deficiencies. For the 2007 complaint reporting period, there were nine deficiencies and for the 2008 complaint reporting period, there were thirteen deficiencies.

All nursing home facilities are required by law to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of its residents and misappropriation of resident property. During this time period, Fairview Nursing Plaza failed its residents in this regard in 2008 and actually placed its residents in immediate jeopardy. The facility did not have a wound management system in place to ensure that nursing staff was knowledgeable in the assessment of pressure ulcers to be able to identify them in the early stages, identify potential deep tissue injury, and the signs and symptoms of wound infection. The facility staff failed to ensure wounds were evaluated for response to treatment, sources of pressure eliminated, and that treatment orders were carried out. No specific care plans were developed for wound prevention and treatment as identified and no evidence was found of nursing oversight and supervision to ensure standards of practice were met. In one instance, a resident’s left heel wound began to emit a foul smelling drainage and the facility continued with the same treatment and failed to re-evaluate the wound. Other residents had pressure sores that were improperly identified and some pressure sores were not measured. In another instance, there was no specific care plan for a resident with multiple pressure sores. Moreover, the facility had no treatment or monitoring system planned for this resident. Another resident with a Stage III pressure sore on his left hip was not given the physician-ordered dressing and the wound showed 90% yellow dead tissue and 10% black tissue. As a result of the state survey, the facility was required to perform a skin check on all residents and obtain treatment orders. Resident Care Plans were updated and the affected residents were evaluated by the Certified Wound Care Specialist, who began approved treatment. Facility staff was in-serviced on wound prevention, wound treatment, and protocols. All nursing home residents need comprehensive assessments periodically to update the resident’s goals and current status. In fact, appropriate Care Plans were not in place for the residents suffering from pressure sores.

It is vitally important that nursing home residents receive the correct medications at the correct time. At least two residents at this facility did not receive their medications because the facility had run out of the medications. Nurse managers and floor nurses audited all medication carts to ensure that medications for all residents were available. Nurses were in-serviced on the appropriate procedure for ordering as well as requesting refills.

While it is important for nursing home residents to receive the correct medications, it is equally important that residents do not take any unnecessary drugs. At this facility, a resident with a known history of substance abuse was abusing Fentanyl patches. Fentanyl patches are used for people experiencing chronic pain. Misuse of the patch can create a dangerous "high" that can also be deadly. The resident had been removing the patch before the scheduled day and claimed to have lost the patch several times. Additionally, one time the resident separated the patch and the gel pain medication had been removed. None of these events were reported to the resident’s physician. The resident was found on the floor, unresponsive, with no pulse or respirations. A post-mortem drug screen found a severe Fentanyl overdose had occurred. The Fentanyl patches were kept in the medication room in a box. After this resident's death, it was determined that at least one of the patches was missing and unaccounted for from the box. An investigation was immediately conducted surrounding the missing Fentanyl patch. It was determined that an agency nurse that had worked at the facility had misappropriated the medication and she was banned from the facility. All licensed nursing staff were in-serviced regarding the monitoring and documentation of residents who are prescribed duragesic patches for pain control and the facility’s requirement of shift-to-shift narcotic counts. An additional in-servicing was conducted concerning residents with known histories of substance abuse to prevent the manipulation of a narcotic analgesic patch and the requirement that a physician be notified if there is a patch missing or tampered with.

Any resident entering a nursing home facility without a catheter is to remain without a catheter unless absolutely necessary. Fairview Nursing Plaza failed to ensure the outflow of urine was not hindered by kinked or twisted urinary catheter tubing and that the collection bag for a resident prone to urinary tract infections was not lying on the floor. The facility provided the resident with a clip so that the bag can be maintained on his bed appropriately. All residents who use catheters were inspected for proper placement of bags and tubing. Nursing staff was in-serviced on proper positioning of foley bags and tubing for residents in wheelchairs and beds and the complications that can occur if not properly maintained.

The nursing home environment should be free of any accident hazards and all residents should receive the appropriate supervision and assistive devices to prevent accidents. The Fairview Nursing Plaza also failed its residents in this regard. One resident did not receive the appropriate supervision to prevent him from removing a hot dog from another resident’s tray. This resulted in the resident choking on the hot dog and CPR had to be initiated after the resident stopped breathing. The resident was revived through CPR and transferred to the Emergency Room. Another resident fell from her wheelchair while trying to put her slipper on. The resident was improperly secured in her wheelchair with a lap belt and her fall resulted in bleeding from her nose and lip and a forehead hematoma. As a result of these failures, residents with an increased risk of choking or aspiration were provided green wristbands to wear to help identify them and were placed at tables in the front of the dining room and monitored by a staff member to ensure safety during meals. Nursing staff were in-serviced on the “Green Band” as well as signs of choking. Nursing staff were also in-serviced on restraint use.

In a separate instance, the facility failed to identify a resident’s risk for head injuries. A resident with difficulty ambulating fell a total of seven times in three months. The final fall resulted in the resident striking his head on a brick wall. He was transferred to the emergency room, where he was found to have a right-sided subdural hematoma that required an emergency craniotomy.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. For more information, call us directly at 1 (888) 317-2525 or visit our website at nursinghomejustice.com.

Tennessee nursing homes did not fare well under the new rating system instituted by The Centers for Medicare and Medicaid. Tennessee ranks third worst in the nation in ratings and 30% of its nursing homes received a one star rating - the worst possible. Only the states of Louisiana and Georgia ranked lower than Tennessee in ratings.

Ratings are based on state inspections, staffing levels, and quality measures, such as percentage of residents suffering from pressure sores, urinary tract infections, etc. and ratings are based on as much as three years of accumulated information.

Forty-one percent of Tennessee nursing homes had the lowest possible score in staffing levels and twenty-five percent of nursing homes ranked much below average in quality of care.

Tennessee has had a history of an unprecedented number of nursing home complaints. In 2007, the state conducted 3,035 complaint surveys. For the 2008 survey period from January to early October, that number significantly jumped to 3,694.

The residents of Rosemont Assisted Living Community of Santa Fe seemed to be having a high number of resident falls. A high-number of patient falls tends to indicate that facility residents should not be in the assisted living facility, but rather in a nursing home. Long-Term Care Ombudsman Sondra Everhart tried to discuss her concerns with the facility's executive director, Charles "Joe" Massey, and the Director of Nursing, with no positive results. Massey didn't want to hear about it. Everhart said, "He didn't want us in the building. He didn't want an independent advocate, which is what we are." Massey allegedly told his staff "if you talk to the ombudsman, I will fire you".

Concerned, Everhart contacted the facility owners via mail and the company immediately fired Massey and the head of nursing. Facility staff members were then retrained and all residents were assessed to ensure they were in the right facility.