A list of the most recent deficiencies for Cuba Memorial Hospital Inc S N F. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-08 | 2024-01-05 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-12-08 | 2023-12-07 | 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 | 2022-09-22 | 2022-10-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-22 | 2022-10-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-22 | 2022-10-28 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-22 | 2022-10-28 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-22 | 2022-10-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-22 | 2022-10-21 | 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 | 2022-09-22 | 2022-10-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-09-22 | 2022-10-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-22 | 2022-10-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-22 | 2022-10-20 | N |
| Post nurse staffing information every day. | Health | 2022-09-22 | 2022-10-14 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-22 | 2022-10-14 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-22 | 2022-10-14 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-12 | 2020-02-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-12 | 2020-01-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-12-12 | 2020-01-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-12 | 2020-01-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-12 | 2020-01-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-12-12 | 2020-01-15 | 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 | 2019-12-12 | 2020-01-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-12-12 | 2019-12-27 | 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 | 2018-11-16 | 2019-01-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-11-16 | 2019-01-14 | 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 | 2018-11-16 | 2019-01-14 | 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 | 2018-11-16 | 2019-01-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-11-16 | 2019-01-14 | N |
| Keep all essential equipment working safely. | Health | 2018-11-16 | 2019-01-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-16 | 2019-01-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-11-16 | 2019-01-14 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-11-16 | 2019-01-14 | 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 | 2018-11-16 | 2019-01-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-16 | 2019-01-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-16 | 2019-01-14 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-11-16 | 2019-01-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-11-16 | 2019-01-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-16 | 2019-01-14 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2018-11-16 | 2019-01-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-11-16 | 2018-12-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-22 | Not Fixed | N |
