Cycle 1
Health 2024-05-17 · Fire 2024-05-17
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cuba, NY
Cuba Memorial Hospital Inc SNF
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
140 West Main Street, Cuba, NY
(585) 968-2000
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
61
Certified beds
Average residents
45
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1972-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
4.09
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,087
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 61.40% · Performance 62.50% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.96
Baseline 3.93 hours · Performance 4.49 hours · Measure score 4.96 · Achievement 4.96 · Improvement 2.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0.71% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 141 |
| Staff flu vaccination coverage | 58.9% |
42%
16.9 pts better
|
Numerator 96 · Denominator 163 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
91.2%
5.2 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 97.7% · Q3 97.8% · Q4 95.0% · 4Q avg 96.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
95.3%
2.4 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.0%
0.6 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 4.3% · Q4 5.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
18.5%
17.2 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
6.1%
4.5 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 9.5% · Q3 8.9% · Q4 17.9% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
13.5%
2.9 pts worse
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.0% · Q3 21.7% · Q4 17.5% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.3% |
14.8%
6.5 pts worse
|
16.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 15.2% · Q3 16.7% · Q4 35.5% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 42.3% |
15.1%
27.2 pts worse
|
16.3%
26 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 37.2% · 4Q avg 42.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.6% |
15.5%
20.1 pts worse
|
14.9%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 37.2% · Q3 26.3% · Q4 45.5% · 4Q avg 35.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.9% |
0.6%
4.3 pts worse
|
1.0%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.7% · Q3 9.0% · Q4 2.7% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.4%
1.1 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.2% · Q4 5.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
20.8%
1.3 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 22.5% · Q3 26.9% · Q4 27.7% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
6.9%
1.1 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.4% · Q3 12.2% · Q4 7.7% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.2% |
76.7%
5.5 pts worse
|
81.7%
10.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · 4Q avg 71.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-22 · Fire 2022-09-22
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-12-12 · Fire 2019-12-12
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-17
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-05-17
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-05-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-05-17
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-05-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-05-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-22
E · Potential for more than minimal harm
2024-05-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-05-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-05-17
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-05-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-05-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-05-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-29
D · Potential for more than minimal harm
2024-05-17
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-06-29
D · Potential for more than minimal harm
2024-05-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-17
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-06-29
E · Potential for more than minimal harm
2022-09-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-10-20
E · Potential for more than minimal harm
2022-09-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-20
E · Potential for more than minimal harm
2022-09-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-20
E · Potential for more than minimal harm
2022-09-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Not marked corrected
E · Potential for more than minimal harm
2019-12-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-01-10
E · Potential for more than minimal harm
2019-12-12
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2020-01-27
E · Potential for more than minimal harm
2019-12-12
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-01-15
E · Potential for more than minimal harm
2019-12-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-01-20
D · Potential for more than minimal harm
2019-12-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-02-07
D · Potential for more than minimal harm
2019-12-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-12-27
D · Potential for more than minimal harm
2019-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-06-29
D · Potential for more than minimal harm
2024-05-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-29
D · Potential for more than minimal harm
2024-05-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-29
B · Minimal harm
2024-05-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-29
D · Potential for more than minimal harm
2023-12-08
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-12-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-05
F · Potential for more than minimal harm
2022-09-22
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-22
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-10-20
D · Potential for more than minimal harm
2022-09-22
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-21
B · Minimal harm
2022-09-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-10-14
B · Minimal harm
2019-12-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-01-30
Penalties and ownership
What sits behind the stars
$0
2024-05-17
Payment Denial
Payment Denial · denial start 2024-09-06 · 55 days
55 day denial
Ownership
Cuba Memorial Hospital, Inc.
5% Or Greater Direct Ownership Interest · Organization
Black, Amy
Corporate Director · Individual
Brown, Thomas
Corporate Director · Individual
Cuba Memorial Hospital, Inc.
Operational/Managerial Control · Organization
Cuba Memorial Hospital, Inc.
5% Or Greater Mortgage Interest · Organization
Fox, Ralph
Corporate Director · Individual
Ireland, Ruth
Corporate Officer · Individual
Kane, Hunter
Operational/Managerial Control · Individual
Kane, Hunter
Corporate Officer · Individual
Kunz, Marjanne
Corporate Director · Individual
Rinker, Mark
Corporate Director · Individual
Tackentien, Luke
Corporate Director · Individual
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