Inspection Reports for
Cuba Memorial Hospital Inc SNF
140 West Main Street, Cuba, NY, 14727
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to notify residents' representatives of changes in condition and to provide appropriate treatment and care according to professional standards for two residents.
Complaint Details
The complaint investigation (NY00325631) found that two residents did not receive proper notification to their representatives about changes in condition, and the facility failed to ensure registered nurse assessments and physician orders for treatment of pressure ulcers and adverse reactions to medication.
Findings
The facility failed to notify representatives of changes in residents' conditions and did not ensure registered nurse assessments or physician orders for treatment of pressure ulcers and adverse medication reactions for two residents. Documentation of assessments and notifications was incomplete or absent.
Deficiencies (2)
F 0580: The facility did not immediately notify residents' representatives of changes in condition for two residents, including administration of antipsychotic medication and development of a stage II pressure ulcer.
F 0684: The facility failed to provide appropriate treatment and care according to orders and professional standards, including lack of registered nurse assessments and physician orders for pressure ulcer treatment and adverse medication reactions.
Report Facts
Medication dose: 5
Pressure ulcer size: 0.5
Pressure ulcer size: 0.3
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to resident rights violations, failure to notify family representatives of changes in resident conditions, inadequate treatment and care, and incomplete medical record documentation.
Complaint Details
The complaint investigation (NY00325631) focused on quality of care issues for Residents #28 and #39, including failure to notify family representatives of changes, inadequate treatment and assessments, and improper medication administration.
Findings
The facility failed to ensure a resident's right to refuse treatment, did not notify family representatives timely about changes in residents' conditions, failed to provide appropriate treatment and assessments for pressure ulcers and medication reactions, and did not maintain accurate medical records with correct prescriber information.
Deficiencies (4)
F 0578: The facility administered a pneumococcal vaccine to Resident #10 without consent despite a verbal declination from the Health Care Proxy.
F 0580: The facility failed to notify family representatives timely about changes in condition for Residents #28 and #39, including administration of Haldol without prior notification and delayed notification of a stage II pressure ulcer.
F 0684: The facility did not provide appropriate treatment and care for Residents #28 and #39, including lack of registered nurse assessment for a reddened coccyx area and no physician order for treatment of a stage 2 pressure ulcer, and failure to complete comprehensive assessments after medication reactions.
F 0842: The facility failed to maintain complete and accurate medical records for six residents by not entering medical orders under the correct prescribing provider's name.
Report Facts
Residents reviewed: 15
Residents with incomplete medical records: 6
Medication dosage: 5
Pressure ulcer size: 0.5
Pressure ulcer size: 0.3
Antibiotic dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #1 | Unit Manager Registered Nurse | Documented communication with Nurse Practitioner #1 about Resident #39's reaction to Haldol and obtained orders |
| Nurse Practitioner #1 | Nurse Practitioner | Provided medication orders for Resident #39 |
| Director of Nursing | Director of Nursing | Administered pneumococcal vaccine to Resident #10 and responsible for consent form accuracy |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Administered Haldol injection to Resident #39 |
| Registered Nurse Unit Manager #2 | Unit Manager Registered Nurse | Created antibiotic order for Resident #3 |
| Medical Director | Medical Director | Signed medication orders and provided interview statements regarding expectations for assessments and order entries |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 20
Date: May 17, 2024
Visit Reason
Complaint Survey with 5 Standard Health citations and 15 Life Safety Code citations, all corrected by late June 2024.
Findings
Complaint Survey with 5 Standard Health citations and 15 Life Safety Code citations, all corrected by late June 2024.
Deficiencies (20)
Criminal history record check process
Notify of changes (injury/decline/room, etc.)
Quality of care
Request/refuse/discontinue treatment; formulate advance directive
Resident records - identifiable information
Alcohol based hand rub dispenser (abhr)
Cooking facilities
Doors with self-closing devices
Electrical systems - essential electric system
Electrical systems - other
Fire alarm system - testing and maintenance
Fire drills
Gas and vacuum piped systems - inspection and maintenance
Hazardous areas - enclosure
Means of egress - general
Portable space heaters
Protection - other
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Subdivision of building spaces - smoke barrier
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Dec 8, 2023
Visit Reason
The visit was an abbreviated survey conducted in response to Complaint #NY00328841 regarding alleged improper use of physical restraints and failure to timely report suspected abuse at the facility.
Complaint Details
The complaint investigation was substantiated. The facility was found to have restrained Resident #1 improperly and failed to report the abuse allegation within the required two-hour timeframe to the appropriate authorities. The incident occurred on 11/25/23 but was reported late on 11/27/23 and inaccurately dated as 11/26/23 in official reports.
Findings
The facility failed to ensure that residents were free from physical restraints used for discipline or convenience, specifically restraining Resident #1 by a staff member sitting on a dining table preventing the resident from moving freely. Additionally, the facility did not timely report the alleged abuse to the appropriate authorities, reporting the incident late and inaccurately.
Deficiencies (2)
F 0604: The facility did not ensure residents were free from physical restraints unless medically necessary. Certified Nursing Assistant #1 restrained Resident #1 by sitting on a dining table, preventing movement and using a cellular phone, which was disrespectful and undignified.
F 0609: The facility failed to timely report suspected abuse of Resident #1 to the Director of Nursing, Administrator, and State Survey Agency within required timeframes, resulting in delayed and inaccurate reporting.
Report Facts
Percentage of nursing staff re-educated: 86
Duration staff sat on table: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Named in restraint and abuse findings for sitting on a dining table restraining Resident #1 and using a cellular phone. | |
| Director of Nursing | Signed investigation report and disciplinary action form; interviewed regarding restraint incident and reporting failures. | |
| Hospital Operation Manager #1 | Received initial report and photograph of restraint incident; reported to Director of Nursing and Administrator late. | |
| Administrator | Notified of incident on 11/27/23; responsible for reporting to State Department of Health; acknowledged reporting error. | |
| Social Worker #1 | Interviewed regarding observation of restraint incident and its disrespectful nature. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Dec 8, 2023
Visit Reason
Complaint Survey with 2 Standard Health citations related to reporting of alleged violations and right to be free from physical restraints, both corrected by early January 2024.
Findings
Complaint Survey with 2 Standard Health citations related to reporting of alleged violations and right to be free from physical restraints, both corrected by early January 2024.
Deficiencies (2)
Reporting of alleged violations
Right to be free from physical restraints
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Sep 22, 2022
Visit Reason
Complaint investigation regarding allegations of verbal abuse by a Certified Nursing Assistant (CNA #3) toward multiple residents and failure to timely report and thoroughly investigate abuse allegations.
Complaint Details
Complaint investigation (NY00296464) revealed verbal abuse by CNA #3 to residents #19, 24, and 31, failure to timely report abuse allegations, and inadequate investigation of abuse incidents. CNA #3 was suspended and terminated. The investigation found multiple failures in reporting, investigation, and resident protection.
Findings
The facility failed to protect residents from verbal abuse by CNA #3, did not timely report abuse allegations to the state, and did not conduct thorough investigations including nursing assessments and staff interviews. Additionally, the facility failed to ensure proper use and assessment of bed rails, did not have a full-time Director of Nursing, failed to post daily nurse staffing information, did not ensure required COVID-19 testing for exempt staff, and had an ineffective pest control program with flies observed in resident rooms and dining areas.
Deficiencies (8)
F 0600: The facility did not ensure residents' rights to be free from verbal abuse by CNA #3 toward three residents during care.
F 0609: The facility failed to timely report alleged abuse incidents to the appropriate authorities within 2 hours as required.
F 0610: The facility did not thoroughly investigate alleged abuse incidents involving residents, lacking nursing assessments, staff interviews, and physician contacts.
F 0700: The facility did not ensure appropriate use, entrapment risk assessment, and maintenance of a bariatric portable bed rail for one resident.
F 0727: The facility did not have a designated Registered Nurse serving as Director of Nursing on a full-time basis from 5/25/22 through 9/22/22.
F 0732: The facility did not post daily nurse staffing information including total number and actual hours worked by licensed and unlicensed nursing staff per shift.
F 0886: The facility failed to maintain an infection prevention program ensuring required COVID-19 testing for a staff member with a medical exemption who was not up to date on vaccinations.
F 0925: The facility did not maintain an effective pest control program; multiple flies were observed in resident rooms and dining areas, causing resident discomfort and infection risk.
Report Facts
Days CNA #2 worked: 4
Days CNA #2 worked: 3
Days CNA #2 worked: 3
Days CNA #2 worked: 2
Bed rail movement: 3
Glue board fullness: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in verbal abuse findings and termination |
| Administrator | Responsible for abuse investigation and reporting | |
| Director of Social Work | Conducted resident interviews during abuse investigation | |
| Acting Director of Nursing | Acting DON | Oversaw nursing but not full-time DON; involved in abuse investigation |
| LPN #2 | Licensed Practical Nurse | Reported complaints against CNA #3 and communicated with maintenance about flies |
| RN #3 | Registered Nurse | Performed resident assessments during abuse investigation |
| Maintenance Director | Installed bed rail without compatibility check | |
| Maintenance Supervisor | Interviewed regarding pest control and fly issues | |
| RN #2 | Infection Preventionist | Responsible for COVID-19 testing oversight |
| CNA #2 | Certified Nursing Assistant | Noncompliant with COVID-19 testing requirements |
Inspection Report
Routine
Deficiencies: 1
Date: Dec 12, 2019
Visit Reason
The inspection was conducted as a standard survey to assess compliance with care planning regulations, specifically to verify if a written summary of the baseline care plan was provided to residents or their representatives upon admission.
Findings
The facility failed to ensure that a written summary of the baseline care plan, including initial goals, medications, dietary instructions, and treatments, was provided to the resident or their representative for five of thirteen newly admitted residents reviewed. Interviews with staff revealed inconsistent practices and lack of formal policy or training regarding care plan distribution.
Deficiencies (1)
F 0655: The facility did not provide a written summary of the baseline care plan to the resident or resident's representative within 48 hours of admission for five of thirteen residents reviewed. This included failure to provide initial goals, medication lists, dietary instructions, and treatments as required.
Report Facts
Residents affected: 5
Residents reviewed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Unit Manager | Interviewed regarding care plan distribution practices and recent changes. |
| Social Worker | Interviewed about care plan review and communication with residents/families. | |
| RN #3 | Unit Manager | Interviewed about baseline care plan process and communication. |
| DON | Director of Nursing | Interviewed about awareness and actions regarding care plan distribution. |
| Administrator | Interviewed about expectations for social worker communication and care plan review. |
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