Inspection Reports for
Steuben Center for Rehabilitation and Healthcare
7009 Rumsey Street Extension, Bath, NY, 14810
Back to Facility ProfileCitations (last 4 years)
Citations (over 4 years)
10 citations/year
Citations are regulatory findings recorded during state inspections.
96% worse than New York average
New York average: 5.1 citations/yearCitations per year
24
18
12
6
0
Inspection Report
Annual Inspection
Census: 102
Citations: 8
Date: May 17, 2024
Visit Reason
The inspection was a Recertification Survey with complaint investigations to assess compliance with regulatory requirements for nursing home care.
Complaint Details
The inspection included complaint investigations (NY00314816, NY00316629, NY00302113) related to medication administration, staffing shortages, and call light system failures.
Findings
The facility was found deficient in multiple areas including incomplete care plans, medication administration issues, inadequate assistance with activities of daily living, insufficient nursing staff, improper medication storage, and malfunctioning nurse call systems.
Citations (8)
F 0656: The facility failed to develop and implement a complete care plan for Resident #71 that included measurable objectives and interventions for hearing impairment and hearing aids.
F 0658: Nursing staff did not ensure medications were consumed by residents but left unattended, as observed with Residents #38 and #54.
F 0677: Resident #54 did not receive necessary assistance with activities of daily living, including showers and personal hygiene, resulting in unwashed hair and lack of showering for several weeks.
F 0684: Resident #24's bowel status was not efficiently monitored or treated timely, and the medical team was not notified promptly of complications related to constipation.
F 0725: The facility did not provide sufficient nursing staff to meet resident needs, resulting in long call light wait times and inadequate assistance with daily living activities.
F 0732: Nurse staffing information was not posted daily with accurate resident census or staffing hours, and prior posted sheets were not retained as required.
F 0761: Medication carts and storage rooms contained expired medications, unidentified loose pills, and undated insulin pens, violating proper medication storage requirements.
F 0919: The resident call system was not properly maintained; some call lights did not function or relay calls properly, and monitors at nurse stations were nonfunctional.
Report Facts
Resident census: 102
Resident census: 103
Medication administration dates: 5
Staffing ratios: 51.5
Shower schedule: 2
Medication expiration dates: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Manager #1 | Licensed Practical Nurse Manager | Stated care plans should include hearing aids and medication carts should be checked for expired medications. |
| Director of Nursing | Director of Nursing | Provided statements on care planning, staffing levels, medication storage, and call system issues. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Reported on care plan use and hearing aid assistance for Resident #71. |
| Physician Assistant #1 | Physician Assistant | Discussed bowel management and notification procedures for Resident #24. |
| Human Resources Director | Human Resources Director | Discussed staffing schedules and call-in tracking. |
| Director of Maintenance | Director of Maintenance | Discussed nurse call system malfunctions and temporary fixes. |
| Assistant Director of Nursing | Assistant Director of Nursing | Reported on medication cart and room audits. |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 12
Date: May 17, 2024
Visit Reason
Multiple quality of care and life safety deficiencies identified, all corrected by July 2024.
Findings
Multiple quality of care and life safety deficiencies identified, all corrected by July 2024.
Citations (12)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Infection control
Label/store drugs and biologicals
Posted nurse staffing information
Quality of care
Resident call system
Services provided meet professional standards
Sufficient nursing staff
Electrical systems - essential electric syste
Elevators
Emergency lighting
Inspection Report
Complaint Investigation
Census: 102
Citations: 1
Date: May 17, 2024
Visit Reason
The inspection was conducted as a Recertification Survey combined with complaint investigations regarding staffing adequacy and resident care.
Complaint Details
The visit was complaint-related, triggered by multiple complaints (NY00314816, NY00316629, NY00302113) about insufficient staffing and inadequate resident care. Resident and family interviews substantiated staffing shortages and care delays.
Findings
The facility did not ensure sufficient nursing staff to meet resident needs, resulting in delays in activities of daily living such as showers, toileting, and answering call lights. Multiple residents and staff reported inadequate staffing, especially on evening and night shifts, leading to compromised care.
Citations (1)
F 0725 - The facility failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift. Staffing shortages caused delays in care including showers, hygiene, toileting, and answering call lights.
Report Facts
Resident census: 102
Resident census: 103
Residents per licensed nurse: 51.5
Residents per Certified Nursing Assistant: 51.5
Residents per licensed nurse: 34
Certified Nursing Assistants: 6
Certified Nursing Assistants: 2
Residents on unit: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Reported staffing shortages and inability to complete showers on evening shifts |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Reported working alone on some shifts and inability to provide full care |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Reported call-ins causing short staffing and inability to complete nail care and showers |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Reported weekend short staffing and facility expectation for residents to be in bed by 7:00 PM |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Reported working alone on night shifts and difficulty completing showers and transfers |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Reported resident #54 did not receive shower due to staffing shortages |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Reported difficulty completing showers, transfers, feeding, and nail care due to staffing |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Reported staying longer than scheduled to complete treatments, which were not timely |
| Licensed Practical Nurse Manager #2 | Licensed Practical Nurse Manager | Reported staffing levels on unit and unawareness of missed care tasks |
| Director of Nursing | Director of Nursing | Reported expected staffing levels and unawareness of missed showers and care due to staffing |
| Human Resources Director | Human Resources Director | Responsible for staffing schedule; acknowledged staffing challenges and missing call-in data |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Feb 22, 2023
Visit Reason
One isolated quality of care deficiency corrected by March 2023.
Findings
One isolated quality of care deficiency corrected by March 2023.
Citations (1)
Quality of care
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 9
Date: Apr 14, 2022
Visit Reason
Multiple quality of care and life safety deficiencies identified and corrected by May 2022.
Findings
Multiple quality of care and life safety deficiencies identified and corrected by May 2022.
Citations (9)
Criminal history record check process
Physical environment
Standards of construction for new nh
Corridor - doors
Development of communication plan
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Fire drills
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Citations: 0
Date: Apr 14, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Steuben Center for Rehabilitation and Healthcare.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Citations: 9
Date: Dec 12, 2019
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with regulatory requirements for nursing home care.
Complaint Details
The inspection included a complaint investigation (#NY00247019) related to activities of daily living care deficiencies.
Findings
The facility was found deficient in multiple areas including resident dignity, baseline care plan documentation, care plan implementation, activities of daily living assistance, pressure ulcer care, hydration monitoring, respiratory care, medication storage, and provision of special eating equipment.
Citations (9)
F 0550: The facility failed to maintain resident dignity for Resident #24 who was observed unclothed and incontinent with the door open and visible from the hallway.
F 0655: The facility did not provide a summary of the Baseline Care Plan to 12 residents and lacked signatures and documentation of provision to residents or representatives.
F 0656: Resident #42 was not wearing physician-ordered Prevalon boots, and the care plan did not include this intervention.
F 0677: The facility failed to provide timely incontinence care for Resident #24 and consistent showers for Resident #20 as per care plans.
F 0686: Resident #60 with pressure ulcers did not receive recommended low air loss mattress or ROHO cushion timely, and care plan revisions were delayed.
F 0692: The facility did not consistently monitor or document fluid intake for Residents #20 and #70, resulting in failure to follow physician-ordered fluid restrictions.
F 0695: Resident #42 received oxygen at 3.5 liters per minute instead of ordered 2 liters, and Resident #60's humidifier bottle was not changed weekly as ordered.
F 0761: Medication storage was deficient with an unsecured narcotic box, undated insulin pens in use, and incomplete narcotic count sheets.
F 0810: Resident #20 did not consistently receive special eating equipment such as a plate guard as recommended by therapy.
Report Facts
Residents reviewed for Baseline Care Plans: 14
Residents reviewed for Baseline Care Plans with deficiencies: 12
Residents reviewed for activities of daily living: 4
Fluid restriction ordered for Resident #20: 1500
Fluid restriction ordered for Resident #70: 1200
Pressure ulcer size for Resident #60: 4.5
Pressure ulcer size for Resident #60: 5
Pressure ulcer size for Resident #60: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Provided statements regarding Resident #24 care and incontinence |
| Certified Nursing Assistant #2 | CNA | Provided statements regarding Resident #24 care and incontinence |
| Director of Nursing | Director of Nursing | Provided statements on expectations for resident dignity and care plan updates |
| Registered Nurse Manager | RN Manager | Provided statements on resident care, care plan deficiencies, and wound care |
| Licensed Practical Nurse #1 | LPN | Provided statements on Resident #42 oxygen and care |
| Occupational Therapist | Occupational Therapist | Provided statements on use of Prevalon boots and assistive devices |
| Wound Care Nurse Practitioner | Nurse Practitioner | Provided statements on Resident #60 pressure ulcer status and treatment |
| Attending Physician | Physician | Provided statements on wound care and mattress availability |
| Diet Tech | Diet Technician | Provided statements on fluid intake monitoring and dietary notifications |
| Licensed Practical Nurse #2 | LPN | Provided statements on Resident #60 oxygen humidifier bottle |
| Assistant Director of Nursing | ADON | Provided statements on medication storage and insulin pen policies |
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