Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clayberg, The during CMS and state inspections, most recent first.
The facility failed to follow standard precautions and perform hand hygiene during oral medication administration for several residents. An RN and an LPN did not perform hand hygiene before or after administering medications. Additionally, an LPN picked up a dropped B-12 tablet with bare hands and administered it to a resident, contrary to facility policy. The DON confirmed the expected procedures.
A facility failed to follow the care plan for a resident with a history of a stage 4 pressure ulcer, who was observed without required heel protectors while in a wheelchair. The care plan, initiated in July 2024, mandated the use of bilateral heel protectors due to the resident's fragile skin and limited mobility. Observations in April 2025 confirmed the absence of heel protectors, and a CNA verified that the resident did not use them in the wheelchair.
The facility did not post the required daily nurse staffing information, including the resident census and actual hours worked per shift, as per their policy. This issue was observed on several occasions, and the DON confirmed the absence of this information, attributing it to the midnight staff, which is mostly agency staff. Despite reminders, the necessary details were not consistently recorded, affecting all 45 residents in the facility.
A resident with severe mental impairment fell out of bed and sustained a skin tear due to staff not being trained on the proper use of an alternating pressure and low air loss mattress. The static button, which stabilizes the mattress, was not activated during care, leading to the incident.
The facility failed to ensure that residents receiving antipsychotic medications had relevant clinical indications and diagnoses. Several residents were prescribed antipsychotic medications without appropriate diagnoses, and observations and staff interviews confirmed the absence of significant behaviors warranting such medications.
The facility failed to provide the required Notice of Transfer for two residents who were hospitalized. One resident was transferred to a local hospital and then to another hospital without receiving the Notice of Transfer. Another resident with multiple hospitalizations also did not receive the Notice of Transfer, despite the facility's policy requiring such notification.
The facility failed to prevent cross-contamination during a pressure ulcer treatment for a resident. An RN did not perform hand hygiene after removing soiled gloves and before donning new gloves, violating standard precautions and the facility's policies on skin breakdown prevention and treatment.
The facility failed to label opened multi-dose insulin pens and vials with the date opened for two residents, as required by their medication policy. An LPN and the DON verified the absence of the labels.
A CNA failed to perform proper hand hygiene during incontinence care for a resident with a urinary tract infection and on contact isolation precautions. The CNA repeatedly changed gloves without using hand sanitizer, contrary to the facility's Standard Precautions policy.
Failure to Follow Hand Hygiene and Medication Handling Protocols
Penalty
Summary
The facility failed to adhere to standard precautions and perform hand hygiene during the administration of oral medications for eight residents. Specifically, a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) did not perform hand hygiene before or after administering oral medications to the residents. Additionally, the LPN was observed dropping a B-12 tablet onto the medication cart surface and then picking it up with bare hands before placing it in a medicine cup with other medications, which was then administered to a resident. The facility's policy clearly states that hand hygiene should be performed before and after medication administration and that medications dropped onto surfaces should be discarded, not administered. The Director of Nursing confirmed these procedures during interviews.
Failure to Implement Heel Protectors for Resident with Skin Impairment Risk
Penalty
Summary
The facility failed to adhere to its plan of care for a resident with a potential for skin impairment, specifically regarding the use of heel protectors. The resident, who has a history of a stage 4 pressure ulcer on the right heel and other conditions such as fragile skin, limited mobility, and edema, was observed without heel protectors while in a wheelchair. The plan of care required the use of bilateral heel protectors when the resident was in the wheelchair, initiated in July 2024. However, during observations on April 2 and April 4, 2025, the resident was seen without the required heel protectors. A CNA confirmed that the resident did not wear heel protectors in the wheelchair and that there were no heel protectors in the resident's room.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information, including the resident census and actual hours worked per shift for nursing staff, as mandated by their policy revised in July 2016. This deficiency was observed on multiple occasions, specifically on 4/1/25, 4/2/25, and 4/4/25, where the posted staffing sheets lacked the necessary details. Additionally, historical staffing sheets from March 2025 also did not include the required information for RNs, LPNs, and CNAs. The Director of Nursing (DON) confirmed the absence of this information and acknowledged that the responsibility for posting the census lies with the midnight staff, which is primarily composed of agency staff. Despite reminders and postings to ensure compliance, the required information was not consistently recorded. The facility's Resident Bed List Report indicated that 45 residents were residing in the facility at the time of the survey.
Failure to Train Staff on Proper Use of Equipment Leads to Resident Fall
Penalty
Summary
The facility failed to train staff on the proper use of an alternating pressure and low air loss mattress, which led to a fall incident involving a resident. The resident, who had severe mental impairment and required substantial help for toileting and transfers, was given a new air mattress from hospice. During an attempt to provide incontinent care, the resident rolled out of bed because the static button on the mattress, which stabilizes it, was not activated. The staff involved were unaware of the need to use the static button, as they had not been trained on this specific equipment feature. The incident occurred when two CNAs were in the process of providing care to the resident. One CNA left the room to get supplies, leaving the other CNA by the bedside. The resident, who was lying on his right side, suddenly rolled out of bed, and the CNA present could not prevent the fall. The resident sustained a skin tear to his left elbow. Interviews with the staff revealed that they were not informed about the static button's function until after the fall occurred. The hospice nurse and equipment manager confirmed the importance of using the static button to stabilize the mattress during care. Further investigation showed that the equipment delivery driver had verbally instructed one CNA on the mattress's operation, but no written instructions were provided. The facility's Director of Nursing and Administrator were unaware of the need to wait six minutes after pressing the static button before starting care. This lack of comprehensive training and communication led to the resident's fall and injury.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents receiving antipsychotic medications had relevant clinical indications and diagnoses for their use. Specifically, five residents were identified as receiving antipsychotic medications without appropriate diagnoses. For instance, one resident was prescribed Aripiprazole, Buspirone, Escitalopram, and Lamotrigine for mood disorders and anxiety, despite having no signs of mania or psychosis. Another resident was prescribed Divalproex and Quetiapine for behaviors related to dementia, even though the resident was more alert and receptive to non-pharmacological interventions after a dose reduction. Additionally, one resident was receiving Seroquel for dementia with agitation, but the resident's MDS assessment documented no behavioral symptoms that impacted the resident or others. Observations and interviews with staff confirmed that the resident had not exhibited aggressive behaviors for a significant period. Another resident was prescribed Olanzapine for mood disorder and dementia with behaviors, but the care plan did not include targeted behaviors or non-pharmacological interventions. Observations and staff interviews indicated that the resident had not exhibited any significant behaviors. Lastly, a resident with severely impaired cognition and multiple diagnoses, including Alzheimer's disease and depression, was receiving Quetiapine for behavioral disturbance. Observations noted the resident exhibiting nonsensical speech and wandering but no physical behaviors. The facility's psychiatry service documented the resident's history of major depressive disorder and dementia. Staff confirmed that antipsychotics should be used for residents with psychotic diagnoses like schizophrenia and bipolar disorder, which were not present in these cases.
Failure to Provide Notice of Transfer for Hospitalized Residents
Penalty
Summary
The facility failed to provide notice of transfer for two residents reviewed for hospitalization. For Resident 39, the Progress Note dated 9/13/23 documented that the resident was taken to the local hospital by facility van for evaluation and was subsequently transferred to another local hospital. However, there was no documentation indicating that a Notice of Transfer was given to Resident 39 or their representative. The Assistant Director of Nursing confirmed that the facility only sends out a Bed Hold form and does not provide a Notice of Transfer to residents or their families. Similarly, the Licensed Practical Nurse in Medical Records confirmed that she was not aware of a Notice of Transfer being given to residents or their families, only the Bed Hold form and other medical documents were sent with the resident during transfers to the hospital. For Resident 43, who has a history of Atrial Fibrillation, Chronic Kidney Disease, Dementia, and Congestive Heart Failure, the facility provided a Bed Hold notice for multiple hospitalizations but did not provide a Notice of Transfer or the reason for the hospitalizations. The Medication Review Report documented several hospitalizations, but there was no evidence that the required Notice of Transfer was given to the resident or their representative. This lack of proper notification is a violation of the facility's policy and procedure, which mandates that residents or their representatives be informed in writing of the bed-hold and return policy prior to transfers.
Failure to Prevent Cross-Contamination During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to prevent cross-contamination during a pressure ulcer treatment for one resident. During the treatment, an RN and a CNA entered the resident's room with gowns and gloves on. The RN placed wound treatment supplies on the resident's bed and assisted the CNA in providing incontinence care. The RN then picked up gauze and a plastic cup from the bed, soaked the gauze with wound cleanser, and used it to clean the resident's open coccyx wound. After handling the soiled gauze, the RN removed her gloves but did not perform hand hygiene before putting on a new pair of gloves and continuing the treatment. The RN then applied ointment to the wound, wrote the date on the dressing with a pen from her pocket, and applied the dressing without performing hand hygiene after removing the soiled gloves and before touching other items and the resident's wound again. The facility's policies on standard precautions and the prevention and treatment of skin breakdown were not followed. The RN failed to perform hand hygiene after removing soiled gloves and before donning new gloves, which is a critical step to prevent cross-contamination. This lapse in protocol was confirmed by the facility's administrator, who acknowledged that the RN should have performed hand hygiene after removing the soiled gloves and before touching anything else.
Failure to Label Opened Insulin Pens and Vials
Penalty
Summary
The facility failed to ensure that an opened multi-dose diabetic insulin pen and an opened multi-dose insulin vial were labeled with the date opened for two residents. The facility's Administration Medication Policy requires that the date opened be recorded on the container of any multi-dose medication. During an observation, an LPN was found to have stored opened insulin pens and vials for two residents without labels indicating the date they were opened. The LPN verified the absence of the labels, and the DON confirmed that all insulin pens and vials should be dated when opened.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to perform proper hand hygiene during incontinence care for a resident diagnosed with a urinary tract infection and on contact isolation precautions due to an ESBL/bacterial infection in her urine. During the care, a CNA removed soiled gloves and applied new ones without performing hand hygiene in between glove changes. This occurred multiple times while cleansing the resident's perineal and rectal areas, despite the facility's Standard Precautions policy requiring hand hygiene after glove removal and before applying new gloves. The incident was observed by surveyors, and the CNA later confirmed that she did not perform hand hygiene between glove changes, acknowledging that she should have used hand sanitizer. The facility's policy, dated 01/2012, clearly states that hand hygiene is a critical component of standard precautions to prevent cross-contamination and infection. The failure to adhere to these guidelines was identified during an interview, observation, and record review, highlighting a significant lapse in infection control practices.
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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 Cuba
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Graham Hospital | 9.2 mi | — | 9 | 0 |
| Sunset Rehabilitation And Health Care | 9.5 mi | — | 3 | 0 |
| Renaissance Care Center | 10.9 mi | — | 1 | 0 |
| Loft Rehab & Nursing Of Canton | 11 mi | — | 1 | 0 |
| Arcadia Care Havana | 14.6 mi | — | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.