Cuba Memorial Hospital Inc SNF

Inspectors wroteBased on interviews, and record review conducted during survey, the facility failed to protect resident's rights from verbal, mental and physical abuse by another resident for one (Resident #17) of four residents reviewed for abuse. Specifically, on 10/05/2025, Resident #17 was yelled at, grabbed by their arms and thrown back into their wheelchair by Resident #3. Following the abusive interaction, Resident #17 displayed emotional distress and was observed crying. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity guide, this resulted in psychosocial harm to Resident #17, that is not Immediate Jeopardy.

Inspectors wroteBased on interview and record review conducted during a survey, the facility failed to ensure that all alleged violations of abuse and neglect were thoroughly investigated for two (Residents #2 and #6) of six residents reviewed. Specifically, the facility did not maintain documentation that an alleged violation was thoroughly investigated.

Inspectors wroteBased on observations, interviews, and record review conducted during the survey, the facility failed to ensure the nursing staff information was posted on a daily basis and contained the required information. Specifically, the facility did not post daily the current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff, in a prominent place readily accessible to residents and visitors for two out of five days; the facility did not complete and update the form, each shift, to include accurate resident census, and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care for five out of five days. Additionally, the facility failed to retain records for 18 months per regulation.

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 5/17/24, the facility did not ensure that a resident has the right to refuse treatment for one (Resident #10) of five residents reviewed for immunizations. Specifically, Resident #10 was administered the pneumococcal vaccine (used to prevent pneumonia) by facility staff without consent. The finding is: The policy and procedure titled Resident Rights dated 10/22 documented the facility will protect and promote the rights of the resident. The policy and procedure documented the resident had the right to accept or refuse care and treatment. [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 5/17/24 the facility did not immediately inform resident's representatives of a change in their physical and/or mental status for two (Resident #39 and Resident #28) of three residents reviewed for notification of change. Specifically, Resident #39 was given an intramuscularly injection (IM) of Haldol (antipsychotic medication) 5 milligrams and the family was not notified until after the resident had an adverse reaction to the medication. Additionally, the facility did not notify Resident #28's representative of a reddened area on their coccyx until 6 days later, and there was no documented evidence Resident #28's representative was notified of a stage II pressure area.

Inspectors wroteBased on interview and record review conducted during a Complaint (NY00325631) investigation conducted during a Standard Survey completed on 5/17/24, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for two (Resident #28 and #39) of fifteen residents reviewed for quality of care. Specifically, there was no Registered Nurse assessment for a resident with a reddened area on their coccyx, and there was no order obtained from the physician for treatment of a Stage 2 (a shallow wound that affects the skin and the tissue below it) pressure ulcer (#28). Additionally, there was no evidence of a Registered Nurse assessment for a resident who experienced a change in their behavior, received an antipsychotic medication and after the resident had an adverse reaction to the medication (Resident #39).

Inspectors wroteBased on record and interview review conducted during a Standard survey completed on 5/17/24, the facility did not maintain complete and accurately documented medical records for six (Resident #3, #10, #25, #36, #39, and #41) of 16 residents. Specifically, medical orders were not accurately entered under the prescribing providers name in the medical record.

Inspectors wroteBased on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00328841) completed on 12/8/23, the facility did not ensure that residents were treated with respect and dignity, free from physical restraints for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (Resident #1) of four residents reviewed. Specifically, Certified Nursing Assistant #1 was observed by a staff member to have sat Resident #1 into a standard chair in the dining room where the back of the chair was against the wall with a window, pushed the dining table up to the resident's chair, then proceed to sit on top of the dining table preventing the resident from moving freely from the table. [...]

Inspectors wroteBased on interview and record review conducted during an Abbreviated survey (Complaint #NY00328841) completed on 12/8/23, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse, to the facility's Administrator and the State Survey Agency for one (Resident #1) of four residents reviewed for abuse. Specifically, facility staff did not report an allegation of abuse/mistreatment of a resident to the Director of Nursing or the Administrator which resulted in the alleged abuse not getting reported to the appropriate officials including the New York State Department of Health as required. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey started on 9/18/22 and completed on 9/22/22, the facility did not have a designated Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis. Specifically, the Acting RN Director of Nursing was not designated as the DON from 5/25/2022 through 9/22/22 on a full-time basis. The finding is: The undated facility job description for the DON provided by the Human Resource (HR) Manager documented the DON provides administrative and clinical leadership and direction for nursing practice with 24-hour accountability on her/his nursing units. Assures the delivery of comprehensive, safe and effective nursing care in accordance with the established policies and procedures of the long-term care (LTC) nursing department. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey started 9/18/22 and completed 9/22/22, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Specifically, one (Unit 3) of two units were observed to have black houseflies in residents' rooms and in the dining room. This involved Residents #8, 14, 24, 28, and 31.

Inspectors wroteBased on observation, interview, and record review conducted during a complaint investigation (NY00296464) completed during a Standard survey started 9/18/22 and completed 9/22/22, the facility did not ensure the resident's rights to be free from abuse for three (Resident #19, 24 and 31) of four residents reviewed for abuse. Specifically, it was determined CNA #3 was verbally abusive to three residents during care.

Inspectors wroteBased on interview and record review during a complaint investigation (NY00296464) completed on a Standard survey started 9/18/22 and completed 9/22/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Four (Resident #3, 19, 24, and 31) of four residents reviewed for abuse were involved in incidents either not reported or not reported timely to the New York State (NYS) Department of Health (DOH) as required. Specifically, resident to resident altercation (#3 and 31) and allegations of verbal abuse (#19, 24 and 31).

Inspectors wroteBased on interview and record review conducted during a complaint investigation (NY00296464) completed on a Standard survey started 9/18/22 and completed 9/22/22, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for four (Residents #3, 19, 24, and 31) of four residents reviewed. Specifically, there was a lack of a thorough investigation to include nursing assessments, interviews with staff and other potential victims into alleged verbal abuse by a certified nursing assistant (CNA) (Residents #19, 24, and 31) and into a resident-to-resident confrontation (Residents #3 and 31).

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey started on 9/18/22 and completed 9/22/22, the facility did not ensure appropriate use, entrapment risk assessment, and maintenance of bed rails for one (Resident #25) of one resident reviewed for bed rail use. Specifically, the facility did not follow manufacturer's instructions on proper use of a bed rail, did not perform an entrapment risk assessment prior to installing a bariatric portable bed rail to the adjustable hospital bed frame, and did not implement a routine monitoring system to protect residents from entrapment risk when using bed rails. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey started on 9/18/22 and completed 9/22/22, the facility did not maintain an infection prevention and control program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility had no documented evidence that one (Certified Nursing Assistant (CNA) #2) of three staff reviewed for COVID-19 testing, whom were not up to date with their COVID-19 vaccinations, were tested for COVID-19 as required. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey started on 9/18/22 and completed on 9/22/22, the facility did not post, on a daily basis, the following information: the facility name, current date, the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The finding is: Review of the policy and procedure (P&P) titled Staff Census Posting dated 9/21/22 documented based on days scheduled provided by the schedular, the unit secretary will post the Daily Census Sheet in a public place breaking down the number of Registered Nurses (RN's) Licensed Practical Nurses (LPN's) and Certified Nursing Assistants (CNA's) working that day and on that unit. 1. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 12/12/19, the facility did not ensure that a written summary of the baseline care plan, that included initial goals, a list of current medications, dietary instructions, and services/ treatments to be administered by facility personnel acting on behalf of the facility, was provided to the resident or the resident's representative. Specifically, five (Residents #1, 17, 34, 41, 49) of 13 admitted residents reviewed for baseline care plans had no documented evidence that a written summary of the baseline care plan was provided to the resident or the resident's representative by completion of the comprehensive care plan.