Sodus Rehabilitation and Nursing Center hit with finable “Actual Harm” citation

April 12, 2019 06:09 PM

SODUS, N.Y. (WHEC)- A nursing home at the center of a year-long News10NBC investigation has been hit with three new citations by the New York State Department of Health, one of which will have it paying both state and federal fines. 

New inspection records obtained by News10NBC Investigative Reporter Jennifer Lewke show that in February, inspectors from the New York State Department of Health probed the deaths of two separate residents that passed away in January.  In one case, inspectors found that one of the residents “died during the administration of a soap suds enema and it was not investigated to determine the root cause and rule out abuse, neglect or mistreat.”


Under the law, any unexpected death should have been reported to the DOH but this one was not.  When the medical director at Sodus Rehab was questioned about why it wasn’t reported he said, “he relies on the Administrator and the Director of Nursing to do that. He said he was not notified what was going on with the resident before or after her death.” 

According to the records, the Director of Nursing told state inspectors, “she did not do an investigation into the resident’s death but she should have and would do so in the future. The DON said that if she would have completed an investigation, she would have discovered that the resident’s bowel medications were not transcribed or signed off as administered on 1/2/19 and 1/3/19 as ordered by the physician.”

The state inspection records also detail the medical situation of another resident at Sodus Rehab saying, “At 2:50am, the staff heard a crash and found the resident on the floor in the unit dining room with a broken overbed table on her lower legs.” The records go on to detail how the staff member that responded initially just saw a cut on the resident’s hand but over the next few days her condition deteriorated, “…the resident presented with symptoms such as a black eye, slurred speech, not responding to verbal or tactile stimuli, and needing suctioning that should have been reported to the medical staff.”  By the time it was, she was rushed to the hospital where medical records show she had a subdural hematoma with a brain stem herniation and she died a few days later.  

For more than a year, News10NBC has been investigating the care and conditions inside Sodus Rehab.  Patients and family members have told their stories of sub-par medical care, poor living conditions and severe staffing shortages.  News10NBC Investigative Reporter Jennifer Lewke tracked down Ephraim Zagelbaum, the CEO of Personal Healthcare LLC, the company that owns Sodus Rehabilitation and Nursing Center in the New York City area.  He declined to comment and called the police to have her removed from the property but he did replace the Administrator and the Director of Nursing at Sodus shortly after that encounter.  Still—the problems persist.  In fact, the new citations against Sodus Rehab are the most severe it has faced. 

Sodus Rehabilitation and Nursing Center has been cited 90 times since 2015 for health and safety violations but this new citation is more severe than the previous ones.  Inspectors found “actual harm and/or immediate jeopardy” and that triggers both a state and federal fine.  The amount of the fines is still being determined and the investigation is not over.  

News10NBC most recently reported on a case of bedsores that developed on a resident at the facility.  His condition was so deteriorated he nearly died of sepsis by the time he was rushed to the hospital.  His family members have filed a complaint with DOH and have been told it’s currently under investigation.  News10NBC has learned that DOH inspectors have been inside Sodus Rehab almost weekly for the past several months both to investigate new complaints and make sure the facility is following the plans of correction it’s drawn up to address previous citations.    

Members of the New York State Attorney General’s Medicaid Fraud Unit are also conducting an investigation inside the facility yet they’ve been tight-lipped about any developments.  


Jennifer Lewke

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