Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Steuben Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Failure to Administer Ordered Medications and Treatments: Two residents did not receive ordered meds/treatments as scheduled. One resident with bipolar disorder missed quetiapine doses when the pharmacy had not delivered the medication, and the record did not show pharmacy follow-up, MD notification, or alternate orders. Another resident with chronic pain missed lidocaine patch applications when the resident was already out of bed, with no later attempt documented and no MD notification or alternate instructions noted.
An LPN was observed with four unlabeled medication cups containing pre-poured meds for four residents at a med cart. The cups held meds including carbidopa-levodopa, midodrine, gabapentin, and torsemide. The LPN said the residents were in the dining room and the meds would be passed there, and the DON stated pre-pouring meds was never allowed under facility policy.
The facility failed to provide sufficient nursing staff, resulting in unmet needs in activities of daily living such as timely showers, addressing call lights, and assistance with eating, toileting, and personal hygiene. Residents and staff reported long wait times and incomplete care tasks, particularly during evening and night shifts and on weekends.
The facility failed to ensure proper storage of medications in the Keuka and Lamoka Units, with expired medications, unidentified loose pills, and undated insulin pens found in medication carts and storage rooms. Nursing staff were unclear on the process for regular audits, leading to the oversight.
The facility failed to maintain a functional resident call system in three units, leading to the use of an inadequate temporary solution that did not reliably alert staff to residents' calls for assistance.
A facility failed to include a resident's hearing needs in their care plan, despite the resident being diagnosed with hearing impairments and requiring hearing aids. Staff interviews and observations revealed that the resident frequently did not have their hearing aids in, and the care plan was not updated to reflect these needs.
The facility failed to ensure proper medication administration for two residents. One resident with dementia had multiple medications left unattended in their room, and another resident with diabetes had a medication left on their bedside tray table. Nursing staff did not verify medication consumption as required by facility policy.
The facility failed to ensure a resident received necessary services for grooming and hygiene, as the resident had unwashed hair and had not received a shower in several weeks despite being scheduled for showers twice a week. Staffing issues were cited as a reason for the missed showers.
The facility failed to monitor and manage a resident's bowel status according to professional standards and the resident's care plan. Despite the resident's complaints of constipation and the facility's bowel management policy, there was no documented evidence of timely medical provider notification or initiation of treatment, leading to a delay in care and the need for manual disimpaction.
The facility failed to ensure daily posting of accurate nurse staffing information, including the number and hours worked by nursing staff and the resident census. Discrepancies were found between posted information and actual schedules, and updated sheets were not retained.
Failure to Administer Ordered Medications and Treatments
Penalty
Summary
The facility failed to provide medications and treatments as ordered and failed to obtain medical provider direction when ordered medications and treatments were not administered for two residents. The deficiency involved a resident with bipolar disorder, diabetes, and peripheral vascular disease who was ordered quetiapine fumarate 400 mg at bedtime, and a resident with dorsalgia, polyneuropathy, and osteoporosis who was ordered a lidocaine 4% patch to the coccyx each morning for pain and removed at bedtime. For the resident receiving quetiapine, the October MAR documented the medication as code 9 on three occasions. Progress notes stated the medication was not given because it had not yet been delivered by the pharmacy and remained on order. The record did not show that the pharmacy was contacted, the medical provider was notified, or alternative orders were obtained when the medication was unavailable. The resident’s notes during that period did not document mood changes, agitation, lethargy, or withdrawal symptoms. For the resident ordered the lidocaine patch, the April MAR documented code 5 on three mornings, and progress notes stated the patch was not applied because the resident was already out of bed or out of bed before the nurse could apply it. The record did not show later attempts to apply the patch, medical provider notification, or alternative instructions. The resident stated that when the patch was not applied in the morning, pain was worse throughout the day, especially during therapy.
Unlabeled pre-poured medications found on medication cart
Penalty
Summary
Medications were not labeled or handled in accordance with accepted professional principles during a medication cart observation. The facility policy, Medication Administration, last revised December 2019, stated medications may not be prepared in advance. During the observation, an LPN was standing at a medication cart with four unlabeled medication cups containing pre-poured medications intended for four separate residents. The LPN identified the intended resident and the medications in each cup for the surveyor, and the medications included carbidopa-levodopa 25-100 mg, midodrine hydrochloride 2.5 mg, gabapentin 300 mg, torsemide 20 mg, and gabapentin 100 mg. During interview, the LPN stated all residents were in the dining room and the medications would be passed there, and said they knew which medications belonged to each resident and this was how they passed medications. The LPN asked whether writing resident names on the medication cups would be acceptable and then stated they could place the cups in each resident's drawer and pass the medications one resident at a time. The LPN discarded the medications at the direction of the surveyor. The DON later stated that pre-pouring medications was never allowed under facility policy and that the observation involving the LPN was unacceptable.
Insufficient Nursing Staff Leads to Unmet Resident Needs
Penalty
Summary
The facility did not ensure sufficient nursing staff to provide necessary care for residents, leading to unmet needs in activities of daily living such as timely showers, addressing call lights, and assistance with eating, toileting, and personal hygiene. The facility's staffing schedules for April and May 2024 revealed significant understaffing across all shifts, with instances of only two licensed nurses available for 103 residents and frequent absences of nursing supervisors. This resulted in long wait times for residents needing assistance and incomplete care tasks, such as nail care and showers. Residents and their families reported numerous issues related to the lack of staff, including long wait times for call lights, inadequate assistance with toileting, and cold meals due to delays in service. Observations confirmed that residents were often left ungroomed, with dirty nails and unwashed hair. Resident Council meeting notes and interviews with residents highlighted consistent concerns about insufficient staffing, particularly during evening and night shifts and on weekends. Interviews with Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) corroborated the residents' complaints, with staff members acknowledging that they were often unable to complete essential care tasks due to being short-staffed. The Human Resources Director and the Director of Nursing admitted to struggles in maintaining adequate staffing levels, especially during call-ins, but were unaware of the extent to which care was compromised. The facility's failure to provide a comprehensive staffing plan further exacerbated the issue, leaving staff and residents without the necessary support to ensure high-quality care.
Improper Storage of Medications
Penalty
Summary
The facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws. Specifically, the Keuka and Lamoka Units' medication carts contained expired medications, unidentified loose pills, and undated insulin pens. The Keuka Unit medication cart had expired allergy medication, aspirin, and vitamins, with some expiration dates as old as December 2023. Additionally, the Lamoka Unit medication cart contained multiple unidentified loose pills. Interviews with the nursing staff revealed that each nurse was responsible for monitoring their own cart for expired medications, but there was no clear process for regular audits of the medication carts and rooms. The medication storage rooms in both the Keuka and Lamoka Units also contained multiple bottles of expired medications, including vitamins, antacids, stool softeners, laxatives, and nasal sprays, with some expiration dates as old as August 2023. The Director of Nursing and the Assistant Director of Nursing acknowledged that expired medications should not be stored in the medication carts or rooms and that insulin pens should be labeled with resident identifiers and the date they were opened. The Assistant Director of Nursing admitted that while monthly audits were supposed to be conducted, the last audit may not have been thorough enough, leading to the oversight of expired medications.
Deficient Resident Call System Maintenance
Penalty
Summary
The facility did not properly maintain the resident call system in three resident units (Keuka, Lamoka, and [NAME]). 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. A resident complaint was documented in the 'Resident Council: Meeting Minutes' about a broken call light/pull cord in their bathroom, and they were given a tap bell, which the resident did not feel was adequate. Observations revealed that the 'Call to U' brand wireless caregiver pager system was used as a temporary fix, but it had significant limitations, such as only ringing twice and not indicating which resident pressed the call bell, making it difficult for staff to respond promptly and accurately to calls for assistance. Certified Nursing Assistant #2 confirmed that the 'Call to U' system was implemented due to issues with the 'Jeron' push button call lights in several rooms, where some lights turned on without making a sound, and others had no lights or sounds at all. The Director of Maintenance acknowledged the problems with the nurse call system, stating that an electrician was scheduled to address the issues, and the 'Call to U' system was a temporary solution. However, the temporary system had faults, such as the receiver boxes only staying lit for a few seconds and not being carried by staff, which further complicated the ability to respond to calls. Additional observations and interviews revealed that the central nurse call monitoring screens on the Keuka and [NAME] Units were not functional, and the Director of Maintenance admitted that the call system was obsolete. The facility had a proposal in process to replace the call system on the second floor Lamoka Unit and planned to use the parts removed to fix other issues. Despite these plans, the current state of the call system posed a significant deficiency in ensuring residents' ability to summon assistance effectively.
Failure to Include Hearing Needs in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with hearing impairments. Specifically, the care plan and Kardex for a resident diagnosed with Parkinson's disease, dysphagia, and repeated falls did not include any objectives, timetables, or interventions related to the resident's hearing, hearing aids, or communication concerns. Despite assessments indicating the resident was moderately impaired cognitively and had highly impaired hearing, these needs were not addressed in the care plan. Observations and interviews revealed that the resident frequently did not have their hearing aids in, and staff were unaware of the need to include hearing aids in the care plan. Interviews with staff, including a CNA, LPN Manager, and the Director of Nursing, confirmed that the resident's hearing needs should have been included in the care plan. The CNA stated that the resident liked to wear their hearing aids, but they had not been put in for the past week as they were missing. The LPN Manager and Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's hearing needs, and that the omission could lead to new or unfamiliar staff not knowing the resident required hearing aids. This deficiency was identified during a recertification survey and was based on observations, interviews, and record reviews.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility did not provide services that met professional standards of quality for two residents. For Resident #38, who had diagnoses including dementia and high blood pressure, the nursing staff failed to ensure medications were consumed when administered. The resident's Comprehensive Care Plan noted a tendency to pocket medications, but the plan did not include an assessment for safe self-administration. Observations revealed that multiple medications were left unattended in the resident's room, and interviews with nursing staff indicated that they assumed the resident had swallowed the medications without proper verification. Additionally, a medication not prescribed to the resident was found among the unattended pills. For Resident #54, who was cognitively intact and had diagnoses including diabetes and heart failure, a medication cup with a large white pill was observed on the bedside tray table. The resident stated that the nurse had left the medication for them to take later, and the medication was still there after the scheduled administration time. Interviews with nursing staff confirmed that they did not always watch the resident take their medications and sometimes left medications at the bedside. The facility's policy required that medications should not be left at the bedside unless there was a physician's order for self-administration, which was not present in this case.
Failure to Provide Necessary ADL Services
Penalty
Summary
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, who had diagnoses including diabetes, heart failure, and hypertension, was observed to have unwashed hair and had not received a shower in several weeks. The resident's care plan indicated they required assistance with showering or bathing, and their shower schedule was set for Tuesday and Friday evenings. However, the facility could not provide evidence that the resident had received a shower since 4/30/24, and several dates were documented as not applicable in the electronic health record. During interviews, Resident #54 stated that staff sometimes told them there was not enough staff to assist with a shower, and they managed to keep clean by washing certain areas of their body with a washcloth. Certified Nursing Assistant #3 confirmed that they did not think Resident #54 received a shower on 5/14/24 due to staffing issues. Licensed Practical Nurse Manager #1 acknowledged that if a shower was not done on the scheduled day, staff should assist the resident on another day, and reviewed the electronic health record to confirm the last documented shower was on 4/30/24. The facility's failure to provide the necessary services for Resident #54's grooming and hygiene needs was evident through observations, interviews, and record reviews conducted during the Recertification Survey.
Failure to Monitor and Manage Resident's Bowel Status
Penalty
Summary
The facility did not ensure that Resident #24 received appropriate treatment and care in accordance with professional standards of practice, their comprehensive person-centered care plan, and the resident's choices for pain management. Specifically, the facility failed to efficiently monitor the resident's bowel status, initiate timely treatment, or notify the medical team of complications. Resident #24, who had diagnoses including osteoporosis, vertebral compression fractures, and fibromyalgia, was receiving opioids, which have a side effect of constipation. Despite the facility's bowel management policy, there was no documented evidence that the medical provider was notified of the resident's lack of bowel movements for approximately six days. Observations and interviews revealed that Resident #24 expressed difficulty in moving their bowels and felt constipated. Certified Nursing Assistant #9 confirmed that the resident had been very constipated the previous week and required an enema. The Bowel Movement Report indicated no bowel movements documented from 5/1/24 to 5/7/24, except for a small bowel movement on 5/7/24. Nursing Progress Notes lacked documentation of medical provider notification during this period. Physician Assistant #1 noted that the electronic medical record should alert nurses if a resident does not have a bowel movement for three days, but this did not occur for Resident #24. Interviews with staff, including Certified Nursing Assistants and Licensed Practical Nurse Manager #2, highlighted inconsistencies in monitoring and documenting bowel movements. The Director of Nursing confirmed that nurses should run bowel reports at the start of each shift and initiate the bowel regimen if a resident has not had a bowel movement in three days. However, this protocol was not followed for Resident #24, leading to a delay in treatment and the need for manual disimpaction on 5/8/24.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
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, 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. Observations on multiple dates revealed discrepancies in the posted nurse staffing information, such as an incorrect resident census and inaccurate hours worked by nursing staff when compared to the provided nursing schedules. Interviews with the Human Resources Director and the Administrator revealed that the facility had been using a computer system for posting nurse staffing information for approximately a year and a half. However, the system was not updated accurately to reflect changes in staffing, and the posted sheets that identified changes were discarded. The Human Resources Director admitted to shredding the staff sheets that were actually posted until instructed to save them. The Administrator confirmed that the posted staffing information was frequently changed due to staff changes, but the updated sheets were not retained. This failure to maintain accurate and complete nurse staffing information is a violation of 10 NYCRR 415.13.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bath
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ira Davenport Memorial Hospital Snf/hrf | 3.2 mi | ★★★★★ | 0 | 0 |
| Absolut Center For Nursing And Rehabilitation At T | 16.9 mi | ★★★★★ | 0 | 0 |
| Maple City Rehabilitation And Nursing Center | 17.5 mi | ★★★★★ | 0 | 0 |
| Elderwood At Hornell | 17.6 mi | ★★★★★ | 0 | 0 |
| Corning Center For Rehabilitation And Healthcare | 19.7 mi | ★★★★★ | 0 | 0 |
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