A list of the most recent deficiencies for Cuba Manor Inc. 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? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-21 | 2023-11-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-21 | 2023-11-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-21 | 2023-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-21 | 2023-11-04 | 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 | 2023-09-21 | 2023-11-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-21 | 2023-11-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-21 | 2023-11-04 | 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 | 2023-09-21 | 2023-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-21 | 2023-11-04 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-09-21 | 2023-11-04 | 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 | 2023-09-21 | 2023-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-21 | 2023-11-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-21 | 2023-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-21 | 2023-11-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-18 | 2022-06-29 | 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 | 2022-05-18 | 2022-06-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-18 | 2022-06-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-18 | 2022-06-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-18 | 2022-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-18 | 2022-06-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-18 | 2022-06-29 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-18 | 2022-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-18 | 2022-06-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-18 | 2022-06-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-18 | 2022-06-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-18 | 2022-06-29 | 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 | 2019-05-31 | 2019-07-12 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-05-31 | 2019-07-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-31 | 2019-07-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-31 | 2019-07-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-05-31 | 2019-07-12 | N |
