A list of the most recent deficiencies for Havana Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-01-16 | 2024-02-05 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-01-16 | 2024-02-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-16 | 2024-02-05 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-16 | 2024-02-05 | Y |
| Provide or obtain dental services for each resident. | Health | 2024-01-16 | 2024-02-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-05 | 2023-12-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-05 | 2023-12-21 | Y |
| 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. | Health | 2023-12-05 | 2023-12-21 | Y |
| 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. | Health | 2023-11-08 | 2023-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-21 | 2023-11-03 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-12 | 2023-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-12 | 2023-10-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-01 | 2023-09-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-01 | 2023-09-19 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Develop a communication plan. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-11 | 2023-06-05 | N |
| 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. | Health | 2023-05-03 | 2023-05-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-03 | 2023-05-19 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-03 | 2023-05-19 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-03 | 2023-05-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-03 | 2023-05-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-05-03 | 2023-05-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-05-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-03 | 2023-05-19 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-05-03 | 2023-05-19 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-05-03 | 2023-05-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-02 | 2022-12-10 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-24 | 2022-08-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-07 | 2022-08-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-07 | 2022-08-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Develop a communication plan. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-24 | 2022-07-15 | N |
| 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. | Health | 2022-06-10 | 2022-06-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-06-10 | 2022-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-10 | 2022-06-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-10 | 2022-06-25 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-06-10 | 2022-06-25 | N |
| 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. | Health | 2022-05-03 | 2022-05-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-03 | 2022-05-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-03-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-09 | 2022-03-25 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-09 | 2022-03-25 | N |
| Report COVID19 data to residents and families. | Health | 2022-02-09 | 2022-03-08 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-12-28 | 2022-01-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-28 | 2022-01-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-28 | 2022-01-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-28 | 2022-01-19 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-28 | 2022-01-19 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-28 | 2022-01-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-29 | 2021-10-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-19 | 2021-09-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-19 | 2021-09-10 | Y |
| 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. | Health | 2021-08-19 | 2021-09-10 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-03-17 | 2021-04-02 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-03-11 | 2021-04-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-11 | 2021-04-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-11 | 2021-04-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-03-11 | 2021-04-02 | N |
| 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. | Health | 2021-03-11 | 2021-04-02 | N |
| 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. | Health | 2021-03-11 | 2021-04-02 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-03-11 | 2021-04-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-03-11 | 2021-04-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-11 | 2021-04-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-11 | 2021-04-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-03-11 | 2021-04-02 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-03-11 | 2021-04-02 | N |
