Steuben Center for Rehabilitation and Healthcare

Inspectors wroteBased on interviews and record review, the facility failed to ensure medications and treatments were provided as ordered and failed to obtain medical provider direction when ordered medications and treatments were not administered for two (2) of three (3) residents reviewed (Resident #4 and Resident #14). Specifically, Resident #14 did not receive a physician-ordered antipsychotic (prescription drugs primarily used to manage psychosis, such as delusions and hallucinations) medication on three (3) occasions when the medication was unavailable, and Resident #4 did not receive a physician-ordered pain patch on three (3) occasions when the treatment was not applied as ordered.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medications were properly labeled and handled according to accepted professional standards during one (1) of one (1) medication cart observations. Specifically, Licensed Practical Nurse #1 had four (4) unlabeled medication cups containing pre-poured medications intended for four (4) residents.

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey and complaint investigations (NY00314816, NY00316629, NY00302113), it was determined that the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents in the facility. Specifically, there was not sufficient staff to meet all resident needs with activities of daily living, including timely showers, long waits for addressing call lights and assistance with activities of daily living (eating, toileting, personal hygiene.). This is evidenced by but not limited to the following: For additional information see Centers for Medicare/Medicaid Services Form 2567: F677 - Activities of Daily Living Care for Dependent Residents (Resident #54). F732 - Posted Nurse Staffing Information. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, the facility did not ensure that all drugs and biologicals in the facility were properly stored in accordance with State and Federal Laws for two (Keuka and Lamoka Units) of three medication carts and two (Keuka and Lamoka Units) of two medication storage rooms reviewed. Specifically, medication carts contained expired medications, unidentified loose pills and/or insulin pens undated as to when they were opened or when they expired. Medication storage rooms contained multiple bottles of expired medications. This is evidenced by the following: The facility policy Medication-Storage, dated January 2019, revealed that expired, discontinued, and/or contaminated medications should be removed from medication storage areas and disposed of in accordance with facility policy. [...]

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey, it was determined that for the three (Keuka, Lamoka, and [NAME]) of three resident units the facility did not properly maintain the resident call system. Specifically, elements of the nurse call system were not functioning properly, and modifications made to parts of the call system did not relay the call directly to a staff member or centralized workstation.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for 1 (Residents #71) of 23 residents reviewed, the facility did not develop and implement a plan of care for all residents that included measurable objectives and interventions to address all of the resident's medical and physical needs. Specifically, Resident #71's Comprehensive Care Plan and [NAME] (a care plan used by the Certified Nursing Assistants to provide daily care) did not include that the resident was hard of hearing or required hearing aids. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey and complaint investigation (NY00314816) the facility did not provide services, as outlined by the resident's person-centered Comprehensive Care Plan, that met professional standards of quality for 2 (Residents #38 and #54) of 28 residents reviewed. Specifically, nursing staff did not ensure medications were consumed by the residents when administered but instead were left unattended with the residents or at the bedside. This is evidenced by the following: The facility policy, Medication Administration, dated December 2019, documented that medications shall be administered in a safe and timely manner, and as prescribed. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey, for one (Resident #54) of six residents reviewed the facility did not ensure that a resident who is unable to carry out Activities of Daily Living received the necessary services to maintain good grooming and personal and oral hygiene. Specifically, Resident #54 was observed to have unwashed hair and the facility could not provide evidence that the resident had received a shower in several weeks. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, their comprehensive person-centered care plan, and the residents' choices for one (Resident #24) of one resident reviewed for pain management. Specifically, the facility did not ensure the resident's bowel status was efficiently monitored, treatment initiated timely or that the medical team was notified of complications when applicable. This is evidenced by the following: The facility policy, Bowel Management, dated revised November 2021, included that the nursing assistants document the resident's bowel movements every shift in the electronic medical record, including number, size, and consistency. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey, the facility did not ensure the nurse staffing information was posted daily and included the required information. Specifically, the nurse staffing information did not consistently include the accurate number and total hours worked by licensed and unlicensed nursing staff who were directly responsible for resident care, the accurate daily resident census (the number of residents currently residing in the facility) and did not include any changes in nurse staffing throughout the day per the regulations. The facility was also unable to provide the accurate posted staffing sheets for the prior 18 months as required by law. This is evidenced by the following: [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for 12 (Residents #17, #24, #26, #31, #42, #54, #58, #60, #70, #137, #187, and #245) of 14 residents reviewed for Baseline Care Plans, the facility did not provide a summary of the Baseline Care Plan to the resident and their representative. This is evidenced by but not limited to, the following: 1. Resident #24 was admitted to the facility on [DATE] and had diagnoses including diabetes, dementia with behavior disturbance, and major depressive disorder. The Minimum Data Set (MDS) Assessment, dated 9/1/19, revealed that the resident had modified independence in cognitive skills for daily decision making. The Baseline Care Plan form did not include a complete date, or any signature of staff, resident, or resident representative. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of two residents reviewed for dignity, the facility staff did not provide care in a manner that enhanced the resident's dignity. Specifically, Resident #24 was observed intermittently to be in bed, incontinent of bowel and bladder, and unclothed with the room door open and visible from the hallway as staff and a visitor passed or entered the room. This is evidenced by the following: Resident #24 has diagnoses including dementia with behavioral disturbance, major depressive disorder, and diabetes mellitus. The Minimum Data Set Assessment, dated 9/1/19, revealed the resident had modified independence for daily decision making, was frequently incontinent of bowel and bladder, and required the extensive assistance of two staff for toilet use. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for edema, the facility did not ensure the implementation of each resident's plan of care. Specifically, Resident #42 was not wearing Prevalon boots per physician orders. This is evidenced by the following: Resident #42 has diagnoses including coronary artery disease, heart failure, and peripheral vascular disease. The Minimum Data Set Assessment, dated 10/21/19, revealed that the resident was cognitively intact. The current physician order included the daily use of bilateral Prevalon boots (heel protector) for protection at all times to relieve pressure off of feet. The current Comprehensive Care Plan and Bedside [NAME] did not include Prevalon boots. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY00247019), it was determined that for two of four residents reviewed for activities of daily living, the facility did not provide the necessary care and services to maintain personal hygiene. Specifically, Resident #24 was not provided incontinence care timely, and Resident #20 was not consistently showered per plan of care. This is evidenced by the following: 1. Resident #24 was admitted to the facility on [DATE] and had diagnoses including diabetes, dementia with behavior disturbance, and major depressive disorder. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined for one of one resident reviewed for pressure ulcers, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, Resident #60 did not receive the recommended specialized mattress (low air loss) or chair cushion (ROHO) for a Stage III pressure ulcer, and the Comprehensive Care Plan was not revised timely to reflect the presence of an actual pressure ulcer and interventions. This is evidenced by the following: Resident #60 has diagnoses including quadriplegia, major depressive disorder, anxiety disorder, and chronic obstructive pulmonary disease. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #20 and #70) of two residents reviewed for hydration, the facility did not have a system in place to ensure that daily fluid intake was consistent with or followed physician orders. Specifically, the physician ordered fluid restrictions were not being consistently monitored or documented, and the Comprehensive Care Plan for Resident #20 did not include current hydration needs. This is evidenced by the following: 1. Resident #20 had diagnoses including hyponatremia, Parkinson's disease, and diabetes. The Minimum Data Set (MDS) Assessment revealed the resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of three residents reviewed for respiratory care, the facility did not provide proper care and treatment. Specifically, Resident #42 was not receiving oxygen as ordered by the physician and the humidifier bottles were undated, and Resident #60's humidification bottle was not changed timely. This is evidenced by the following: 1. Resident #42 has diagnoses including coronary artery disease, heart failure and peripheral vascular disease. The Minimum Data Set (MDS) Assessment, dated 10/21/19, revealed that the resident was cognitively intact and did not include the use of oxygen. The current physician orders included oxygen at 2 liters via nasal cannula to keep oxygen saturation level greater than 95 percent as needed. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of two units reviewed for medication storage, the facility did not ensure that all drugs and biologicals were properly labeled and stored in accordance with State and Federal laws. The issues involved a narcotic box that was not secured to the medication refrigerator, an undated insulin pen that was open and in use, an insulin pen that was dated 11/10/11, and narcotic reconciliation sheets that were incomplete. This is evidenced by the following: Observations on the [NAME] Unit on 12/12/19 at 11:15 a.m. revealed that the medication carts contained a Lantus Solostar insulin pen that was not dated and was in use, and a Basaglar insulin pen that was dated 11/10/11. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for the use of assistive devices, the facility did not consistently provide special eating equipment and utensils for a resident who needed them. Specifically, Resident #20 did not have a plate guard. This is evidenced by the following: Resident #20 had diagnoses including Parkinson's disease, chronic pain syndrome and dementia. The Minimum Data Set Assessment, dated 9/19/19, revealed the resident was cognitively intact and required extensive assistance of one staff member for eating. The Comprehensive Care Plan, dated 4/22/19, included to provide set up help and supervision for eating with straws, plate guard and regular utensils. [...]