Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cuba Manor Inc during CMS and state inspections, most recent first.
Failure to Provide Needed Nail, Perineal, and Toileting Care: Several dependent residents with dementia, diabetes, Parkinson disease, and incontinence were observed with long, jagged fingernails and, in some cases, debris under the nails. Staff also failed to provide full perineal care for one incontinent resident and did not offer toileting or incontinence care before laying another resident down for a nap. Interviews showed staff had inconsistent understanding of who should provide nail care and when toileting or cleansing should occur.
Staff failed to perform mechanical lift transfers safely for two residents who were cognitively impaired and dependent on staff for transfers. During observed transfers, two CNAs used the lift, but the second staff member did not guide or hold the resident while suspended over the floor, and one resident was not centered in the sling and had to be repositioned. Interviews confirmed that two staff should be present and that the resident should be held or guided during the transfer.
Improper Storage and Disposal of Medications: Surveyors found expired, discontinued, and unlabeled medications in the medication room and on a med cart, including insulin, eye drops, artificial tears, tuberculin solution, influenza vaccine, and several discontinued oral meds. A CMT had also saved an unlabeled cup of pills for later administration to a resident who was not available, despite knowing that was not the correct procedure. Staff and leadership identified nurses as responsible for medication room oversight and medication disposal, but the expired and discontinued meds remained stored in the room.
Staff failed to follow infection control practices during incontinence care and resident transfers. CNAs used the same soiled gloves while moving from dirty to clean tasks, did not perform hand hygiene when entering or leaving rooms, and did not disinfect a mechanical lift after use for two residents. An ADON also participated in a transfer after bowel care without hand hygiene. The IP and DON stated hand hygiene is expected when entering and exiting rooms and when moving from dirty to clean tasks, and that lifts and reusable supplies should be cleaned after each resident use.
Failure to Honor Residents’ Preference to Sleep In: Staff did not honor two residents’ stated preference to remain in bed later in the morning. One resident was cognitively intact and said staff forced him/her to get up early every day despite repeated requests to sleep in; the other resident was cognitively impaired, on hospice, and said staff woke him/her very early and made him/her sit in a wheelchair for hours before breakfast even after daily refusals. The DON acknowledged residents should not be forced to get up and that both residents would stay in bed if allowed.
A resident with dental caries, poor dentition, and mouth pain was evaluated by a dentist who recommended oral surgery for multiple teeth, but the record lacked documentation that staff followed up to ensure the dental services were provided. The resident reported missing teeth and difficulty chewing, while the SSD, LPN, and DON described the referral process and mobility barriers, but no documentation showed an oral surgeon appointment was scheduled or completed.
The facility failed to provide an effective activity program for residents, as several were observed asleep in common areas with the TV on, rather than engaged in meaningful activities. Despite the activity calendar and staff expectations, residents with cognitive impairments were not adequately encouraged to participate, leading to a deficiency in meeting their mental and psychosocial needs.
Facility staff failed to limit PRN psychotropic medication orders to 14 days for two residents, lacking specific duration and clinical rationale. One resident, cognitively intact and on hospice, had a Lorazepam order without a 14-day stop date. Another resident, severely cognitively impaired, had a Xanax order with similar issues. Staff interviews revealed oversight in entering orders into the electronic system.
Facility staff failed to properly store and label creams and ointments, with several items found opened, undated, and expired in treatment carts. Interviews revealed a lack of consistent process for checking outdated or unlabeled items, with the LPN, DON, and Administrator unaware of the deficiencies.
Failure to Provide Needed Nail, Perineal, and Toileting Care
Penalty
Summary
Facility staff failed to ensure that residents who were unable to perform activities of daily living received needed assistance with personal hygiene and grooming. The cited concerns involved five residents who were dependent on staff for personal hygiene, toileting, dressing, or showers, and whose records showed diagnoses such as dementia, diabetes, Parkinson disease, impaired range of motion, and incontinence. The facility policies reviewed did not provide guidance on when to perform nail care, perineal care, or toileting/incontinence care, and staff interviews showed inconsistent understanding of when these services should be provided. Resident #3 was cognitively impaired, incontinent of urine and bowel, dependent on staff for toileting, showers, dressing, and personal hygiene, and had dementia and diabetes. Observations showed long, jagged fingernails with dark debris under the nails on multiple occasions. During a later observation, staff provided partial perineal care after incontinence, but did not clean the resident’s abdominal folds, inner thighs, or full perineal area. The CNA stated full perineal care should have been provided and that fingernails were clipped monthly by the nurse. Resident #5, Resident #9, and Resident #37 were also observed with long, jagged fingernails, and in some instances visible debris under the nails. Resident #5 had dementia and diabetes and was observed with long toenails; an LPN stated diabetic nails are trimmed by the podiatrist but did not know whether the resident was on the podiatry list. Resident #9 was dependent on staff for personal hygiene and was repeatedly observed with long fingernails and debris. Resident #37, who had Parkinson disease and was dependent on staff for personal hygiene, was observed with contracted hands, long fingernails, and visible debris under the nails; a CNA stated the nurse trims the nails. Resident #50 was frequently incontinent of urine and occasionally incontinent of bowel, and the care plan directed incontinence care as needed and toileting upon rising in the morning, but did not address toileting or incontinence care before naps. When the resident was transferred to bed for a nap, staff did not offer toileting or provide incontinence care, and both CNAs later stated toileting and cleansing should have been offered before laying the resident down.
Mechanical Lift Transfers Performed Without Proper Resident Support
Penalty
Summary
Facility staff failed to transfer two residents by mechanical lift in a manner that prevented accidents. The facility’s Mechanical Lift policy directed staff to follow the manufacturer’s instructions, but the policy did not provide guidance on the number of staff required during a lift transfer. The manufacturer’s manual stated that two assistants are recommended for lifting preparation and for transferring from and to surfaces, although one assistant may be used based on a healthcare professional’s evaluation. The facility’s orientation guide also did not include guidance for lift transfers from a wheelchair to a bed or for guiding a resident while suspended in the air. Resident #3’s MDS showed the resident was cognitively impaired and dependent on staff for transfers, and the care plan directed transfer by two staff and a mechanical lift. During two observations, CNA A and another CNA used a mechanical lift to move the resident from a reclining wheelchair to a bed, but the second staff member did not guide or hold the resident while the resident was suspended over the floor. Resident #62’s quarterly MDS also showed cognitive impairment and dependence on staff for transfers. During observation, CNA A and CNA B used a mechanical lift to transfer the resident between a wheelchair and bed, but the resident was not centered in the sling and CNA A had to assist repositioning; during both transfers, CNA B did not guide or hold the resident while the resident was suspended over the floor. Interviews with CNA B, CNA A, CNA J, the DON, and the Administrator confirmed that two staff should be present for lift transfers and that staff should hold or guide the resident while suspended for safety.
Improper Storage and Disposal of Medications
Penalty
Summary
Facility staff failed to ensure medications not in use and expired were properly discarded, and failed to ensure medications were labeled in accordance with accepted professional principles. Review of the facility’s medication storage and destruction policies showed discontinued, outdated, or deteriorated drugs were not to be retained for use and were to be returned to the issuing pharmacy or destroyed by two licensed nurses or one licensed nurse and the facility pharmacist. During observation of the East Hall medication room, surveyors found an opened bottle of Genteal eye drops dated 03/31/26, a box of Lantus insulin with an expiration date of 09/30/24, another box of Lantus insulin with an expiration date of 09/30/25, five cards of discontinued Lithium 150 mg tablets, two cards of discontinued Naproxen 500 mg tablets, one card of discontinued Lamotrigine 100 mg tablets, two opened bottles of artificial tears, an opened and undated vial of tuberculin solution, and two unopened influenza vaccine bottles with an expiration date of 06/30/25. Surveyors also observed an unlabeled cup of pills in a medication cart drawer. A CMT stated the medications had been prepared for a resident who was not available and were being saved for later administration, although he/she knew that was not the correct procedure. An LPN stated nurses and medication technicians were responsible for ensuring expired, outdated, and discontinued medications were returned or destroyed, and the DON stated the charge nurse was responsible for the medication room contents, that medications to be returned should be sent back weekly, and that medications requiring destruction should be destroyed immediately with two nurses present. The DON and Administrator both stated CMTs were not allowed to dispose of medications, and the Administrator stated expired, outdated, or discontinued medications could be given inadvertently or would not be effective if given.
Failure to Perform Hand Hygiene and Clean Mechanical Lift Between Resident Uses
Penalty
Summary
Facility staff failed to use appropriate infection control procedures during incontinence care for three residents and failed to clean a mechanical lift after use for two residents. During observations, CNAs performed bowel incontinence care and then continued with other tasks while wearing the same soiled gloves, including changing clothes, touching clean linens, applying powder, handling the lift sling, gathering trash, touching doorknobs, and moving residents without performing hand hygiene. In multiple instances, staff did not change gloves or sanitize hands when moving from dirty tasks to clean tasks, and they did not perform hand hygiene before leaving the resident rooms. For Resident #3, CNA A and CNA B used a mechanical lift to transfer the resident from wheelchair to bed. CNA B removed the brief, discarded it, gathered trash and soiled linens, and touched the doorknob while still gloved. CNA A then wheeled the lift into the hallway without disinfecting it, and neither CNA performed hand hygiene before leaving the room. For Resident #62, CNA A and CNA B used the lift for transfer, wiped bowel movement from the resident, applied powder, touched clean clothes and the lift sling with the same soiled gloves, and then transferred the resident back to the wheelchair and arranged bedding without hand hygiene; the lift was again taken to the hall without being cleaned. For Resident #18, CNA C performed bowel incontinence care and then changed the resident's clothes with the same soiled gloves. CNA C and the ADON did not perform hand hygiene and transferred the resident with the mechanical lift to the wheelchair, then wheeled the resident to the dining room. The facility's IP and DON stated that hand hygiene should occur when entering and exiting rooms and when moving from dirty to clean tasks, and that mechanical lifts and reusable supplies should be cleaned after each resident use.
Failure to Honor Residents’ Preference to Sleep In
Penalty
Summary
Facility staff failed to promote and facilitate resident self-determination by not honoring two residents’ preferences to sleep later in the morning. The report states that Resident #33 was cognitively intact, responsible for himself/herself, and had a care plan that did not include guidance for a preference to sleep in or remain in bed later in the day. During interview, the resident said he/she felt forced to get up early every morning, told staff daily that he/she did not want to get out of bed early, and felt staff did not listen or respect him/her as a human being. The DON stated the resident preferred to stay in bed all the time and that staff encouraged him/her to get up, noting the resident had sores that made being in bed worse, but also said the resident would let staff know if he/she did not want to get up. Resident #58 was assessed as cognitively impaired and receiving hospice services, and the care plan also did not include direction or guidance for a preference to sleep in or rise later in the morning. The resident said staff came in very early every day, woke him/her up, and made him/her sit in a wheelchair for hours before breakfast, despite the resident telling staff every day that he/she did not want to get out of bed just to eat a few bites. The DON stated the resident would stay in bed all the time if given the option and should not be forced to get out of bed, while also noting the resident needed assistance with eating and should not eat in bed. The DON and administrator both stated residents should have the option of sleeping in if they choose and should never be forced to get up.
Failure to Ensure Recommended Dental Care Was Provided
Penalty
Summary
Facility staff failed to ensure dental care services were provided as recommended by a dentist for one resident. The resident’s MDS showed cognitive intactness, a diagnosis of dental caries, and abnormal mouth tissue with obvious or likely cavities or broken natural teeth, along with mouth or facial pain, discomfort, or difficulty chewing. The care plan stated staff were to assist with dental/oral hygiene needs and noted the resident had own teeth in poor condition. The physician order set allowed the resident to be seen by a dental provider as needed. The resident’s dental visit summary stated the resident had a compromised medical disposition and that oral surgery should be completed under the medical license of an oral surgeon, with multiple teeth needing removal in four to six areas of the oral cavity. The medical record showed an oral surgery referral was sent to the contracted dental service provider, but there was no documentation that staff followed up to ensure dental care services were provided. During interviews, the resident said he/she had lost teeth, had not had a dental appointment requested, and wanted dentures because some food was hard to chew. The SSD, LPN, and DON each described the referral process and the resident’s mobility limitations, but the record did not contain documentation that an oral surgeon appointment was scheduled or that dental services were completed.
Failure to Engage Residents in Activities
Penalty
Summary
The facility staff failed to provide an ongoing activity program designed to meet the interests, mental, and psychosocial well-being of five dependent residents out of 24 sampled residents. The facility's policy directed the Activity Director (AD) to plan and organize activities for residents on both group and individual levels. However, observations showed that several residents were often found asleep in common areas with the TV on, indicating a lack of engagement in meaningful activities. The activity calendar listed various activities, but there was no evidence that these were effectively implemented for the residents observed. Resident #11 was assessed as severely cognitively impaired and was observed multiple times with eyes closed, either in bed or in the common area with the TV on. Similarly, Resident #13, who was moderately cognitively impaired, was also observed in the common area with eyes closed and the TV on during scheduled activities. Resident #20, with severe cognitive impairment, was found asleep in the common area during a church activity, and staff did not attempt to engage him/her. Resident #29, who valued religious activities, was also observed asleep during a church activity without staff intervention. Resident #52, moderately cognitively impaired, was observed in the front living area without engagement in activities. Interviews with staff, including an LPN, the AD, the Director of Nursing (DON), and the administrator, revealed that there was an expectation for all staff to assist residents in attending activities and ensuring they were awake and engaged. However, the AD admitted to being unable to provide sufficient one-on-one interactions due to the number of residents. The DON and administrator acknowledged that leaving residents asleep in front of the TV was not considered an activity, and staff should encourage residents to participate actively. Despite these expectations, the observations indicated a failure to implement the activity program effectively, leading to the deficiency.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility staff failed to ensure that as-needed psychotropic medication orders were limited to 14 days unless a specific duration and clinical rationale were provided. This deficiency was identified for two residents. The facility's policies did not include a psychotropic medication policy, which contributed to the oversight. Resident #14, who was cognitively intact and receiving hospice care, had an order for Lorazepam without a 14-day stop date or clinical rationale. The medication administration record showed that the resident did not receive the medication during the review period. Resident #45, who was severely cognitively impaired and demonstrated various behavioral symptoms, had an order for Xanax that also lacked a 14-day stop date or clinical rationale. The medication administration record indicated that the resident received Xanax on one occasion. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that the charge nurse is responsible for ensuring compliance with the 14-day limit for PRN psychotropic medications. However, the oversight occurred when entering orders into the electronic system, and the staff did not know why orders were allowed for more than 14 days.
Deficiency in Medication Storage and Labeling
Penalty
Summary
The facility staff failed to properly store and label creams and ointments, as observed during a survey. Several items in the treatment carts were found to be opened and undated, including Nyamyc Nystatin powder, Lidocaine 4% topical cream, Nystatin cream, Clotrimazole and Betamethasone cream, Collagenase Santyl ointment, and Clobetasol Propironate topical solution. Additionally, some items were expired, such as Hydrogel tubes and chlorhexidine gluconate cloths. The facility's Medication Storage policy requires that no discontinued, outdated, or deteriorated drugs or biologicals be retained for use, and the Medication Destruction policy outlines the process for disposing of such items. Interviews with facility staff revealed a lack of a consistent process for checking treatment carts for outdated or unlabeled ointments and creams. An LPN responsible for overseeing the treatment carts admitted to not having a process for checking for outdated items and only occasionally reviewing the carts when a resident is discharged. The Director of Nursing (DON) stated that all nurses are responsible for periodically checking the carts, but was unaware of the expired and unlabeled items. The Administrator also acknowledged reliance on nursing staff and Certified Medication Technicians to check and discard outdated products according to the policy, but was unaware of the deficiencies found.
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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) |
|---|---|---|---|---|
| Steelville Senior Living | 7.3 mi | ★★★★★ | 15 | 0 |
| St James Living Center | 12.3 mi | ★★★★★ | 8 | 0 |
| Life Care Center Of Sullivan | 15.2 mi | ★★★★★ | 11 | 0 |
| Meramec Nursing | 15.2 mi | ★★★★★ | 0 | 0 |
| Stonebridge Owensville | 19.4 mi | ★★★★★ | 21 | 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.