Steere House Nursing and Rehabilitation Center

Based on surveyor observation and staff interview, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety relative to staff practices in obtaining temperatures for the lunch meal.Findings are as follows:Review of the 2022 Food and Drug Administration Food Code, section 4-702.11 states in part, Utensils and food-contact surfaces of equipment shall be sanitized before use.During a follow up visit to the main kitchen on 3/3/2026 at 11:53 AM, the following was observed:-Dietary Cook, Staff H was observed obtaining the holding temperature of a pan of peas. She then removed the thermometer from the peas and obtained the holding temperature of a pan of mashed potatoes without first cleaning and sanitizing the probe (the metal piece of the thermometer that measures the temperature of the food).-Staff H removed the thermometer from the pan of mashed potatoes and then obtained the holding temperature of a pan of ground broccoli without first cleaning and sanitizing the probe.-Prior to obtaining the holding temperature of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to the care of a peripherally inserted central catheter (PICC line- a type of Central Venous Catheter (CVC), inserted peripherally. It is a long thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) for 1 of 1 resident reviewed with a PICC line, Resident ID #34. Findings are as follows:According to Lippincott Nursing Procedures, Ninth Edition page 657, states in part, .Performing a CVC [central venous catheter- dressing change .Use a sterile measuring tape or the incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated .Administering drugs using a PICC .Review the patient's medical record for conformation of catheter type, size, and tip location .Review of a facility policy titled, Vascular Access Devices, PICC Catheter dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure that residents who require dialysis (a medical treatment that filters waste and excess fluid from your blood when your kidneys can no longer function properly) receive such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the residents' goals and preferences for 1 of 2 residents reviewed who receive dialysis, Resident ID #87.Findings are as follows:Review of a facility policy last revised on 8/19/2024 titled, Dialysis Patients; Care of, states in part, .A continuity of care (COC) must be completed and sent to and from nursing facility and dialysis center with each transfer. The charge nurse shall carefully review the COC upon resident return from dialysis to ensure awareness and follow through with any recommendations or interventions necessary.Record review revealed the resident was readmitted to the facility in January of 2026 with diagnoses including, but not limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that nursing staff have the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments, and considering the number, acuity, and diagnoses of the facility's resident population, in accordance with the facility assessment, for 4 of 6 direct care staff reviewed, Staff C, D, E, and F. Additionally, the facility failed to have the appropriate competencies and skill sets relative to care of a peripherally inserted central catheter (PICC line; is a type of Central Venous Catheter (CVC), inserted peripherally. It is a long thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) for 5 of 5 nurses reviewed, Staff C, D, E, G and H.Findings are as follows:Record review of the Facility assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, the facility failed to obtain laboratory services to meet the needs of its residents for 1 of 1 resident reviewed who was ordered a Hemoglobin A1c (HbA1c, a blood test that shows the average level of blood sugar over the past 2 to 3 months) level, Resident ID #3. Findings are as follows: Record review revealed the resident was admitted to the facility in November of 2025 with a diagnosis including, but not limited to, type 2 diabetes mellitus (DM; a metabolic disorder characterized by high blood sugar resulting from the body's inability to use insulin properly and the inability to produce enough insulin). Record review of a progress note dated 2/19/2026, authored by the provider, revealed a plan to check the resident's HbA1c level for his/her DM management, as the resident's last documented HbA1c level was 11.5 (normal HbA1c level is below 5.7). Record review revealed a physician's order, dated 2/19/2026, to obtain a HbA1c on 2/24/2026. Record review of the laboratory results failed to reveal evidence that the HbA1c was obtained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biological's in accordance with currently accepted professional principles relative to 1 of 2 medication rooms observed, 2 of 5 medication carts observed, and 1 of 1 resident observed with medications stored at his/her bedside, Resident ID #1. Review of the facility's policy titled Medication Storage states in part, Medications and biological's are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel .Outdated, contaminated, discontinued, or deteriorated medications are immediately removed from stock, disposed of according to procedures for medication disposal . 1a. During a surveyor observation on [DATE] at 1:37 PM in the presence of Licensed Practical Nurse, Staff C, of the third-floor medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections by failing to place residents on Enhanced Barrier Precautions (EBP; involves using gown and gloves during high-contact resident care activities) for 1 of 3 residents reviewed with a Multi-Drug Resistant Organism (MDRO) infection, Extended Spectrum Beta Lactamase (ESBL-an infection that is resistant to multiple antibiotics), Resident ID #27. Additionally, the facility failed to provide a sanitary environment and to help prevent the development of infections for 1 of 2 residents reviewed relative to the use of a Bilevel positive airway pressure device (BIPAP, a device that provides breathing support which is administered through a face mask or nasal mask), Resident ID #44. Furthermore, the facility failed to conduct appropriate infection control practices relative to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 3 residents reviewed for a urinary tract infection (UTI), Resident ID #1. Findings are as follows: Record review revealed that the resident was admitted to the facility in March of 2022 with diagnoses including, but not limited to, mild cognitive impairment and history of falling. Review of a progress note dated 7/27/2024 at 12:03 AM revealed that the resident returned from the hospital following a fall and was diagnosed with a UTI. Additionally, s/he was started on Cephalexin (an antibiotic) 500 milligrams (mg) every 12 hours for 7 days. Review of a physician's order dated 7/27/2024 revealed Cephalexin 500mg give 1 tablet every 12 hours with an end date of 8/2/2024. Record review failed to reveal evidence that a care plan was developed and implemented for the UTI that the resident is currently being treated for. During a surveyor interview on 7/30/2024 at 10:43 AM with Minimum Data Set Coordinator, Staff D, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections relative to disinfecting glucometers (a device used to monitor blood glucose) for 2 of 3 residents observed who require blood glucose monitoring, Resident ID #s 51 and 53; and 1 of 1 resident observed for a wound dressing change, Resident ID #357. Findings are as follows: 1. According to the facility's policy last revised January of 2023 titled, General Infection Control Policies states in part, .All items used for the resident are to be cleaned and disinfected before use and/or are to be designated for the resident's use only .Small non-disposable equipment such as glucometers .are to be cleaned and appropriately disinfected after each use for an individual resident. Manufacturer's guidelines should be followed when cleaning glucometer machines . Review of the glucometer's User Instruction Manual titled, Assure Prism multi, states in part, .For multiple patient use .Cleaning and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.