Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
66% occupied
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 3
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident activities, psychotropic medication orders, and medication storage in the nursing facility.
Findings
The facility failed to provide an ongoing activity program meeting the needs of cognitively impaired residents, failed to limit PRN psychotropic medication orders to 14 days without clinical rationale, and failed to properly label and discard expired creams and ointments in treatment carts.
Deficiencies (3)
Failed to provide an ongoing activity program designed to meet residents' interests and psychosocial well-being for five dependent residents.
Failed to ensure PRN psychotropic medication orders were limited to 14 days unless clinical rationale was provided for two residents.
Failed to store and label creams and ointments properly, including failure to document open dates and discard expired products.
Report Facts
Residents affected: 5
Facility census: 59
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding activity program and psychotropic medication orders |
| Director of Nursing | Director of Nursing | Interviewed regarding activity program, psychotropic medication orders, and medication storage |
| Administrator | Administrator | Interviewed regarding oversight of activity program and medication storage |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding medication storage and treatment cart oversight |
| Activity Director | Activity Director | Interviewed regarding planning and implementation of resident activities |
Inspection Report
Routine
Census: 67
Deficiencies: 9
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, medication management, infection control, and care planning at Cuba Manor Inc nursing home.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accurate resident assessments and care plans, timely destruction of discontinued medications, proper medication regimen review communication, infection prevention practices including proper storage of respiratory equipment, and designation of a qualified infection preventionist.
Deficiencies (9)
Failure to maintain a safe, clean, comfortable and homelike environment including proper maintenance of residents' rooms, bathroom vanities, furniture, and oxygen concentrator filters.
Failure to accurately code oxygen use, chemotherapy, and CPAP use for several residents in assessments.
Failure to complete baseline care plans within 48 hours of admission for two residents.
Failure to develop and implement complete, accurate, and individualized care plans for multiple residents, including failure to update care plans with changes in resident needs.
Failure to provide adequate care and assistance for activities of daily living including showering, nail care, shaving, denture care, and hygiene for several residents.
Failure to communicate pharmacist medication regimen review recommendations to physicians and obtain responses for three residents.
Failure to destroy discontinued and PRN medications in a timely manner for two residents.
Failure to clean and store respiratory equipment and devices in a sanitary manner to prevent infection for four residents.
Failure to designate a qualified infection preventionist with specialized training for the facility's infection prevention and control program.
Report Facts
Facility census: 67
Discontinued Gabapentin capsules: 99
Discontinued Potassium Chloride tablets: 8
Discontinued Haloperidol tablets: 29
Discontinued Baclofen tablets: 339
Pharmacist Medication Regimen Review dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding environmental concerns, care plans, medication destruction, and respiratory equipment storage |
| Assistant to the Director of Nursing | Assistant to the Director of Nursing (ADON) | Interviewed regarding environmental concerns, care plans, medication regimen review communication, and respiratory equipment storage |
| Floor Technician K | Floor Technician | Interviewed regarding maintenance and environmental concerns |
| Certified Nurse Aide B | Certified Nurse Aide | Interviewed regarding maintenance reporting and resident care |
| Administrator | Facility Administrator | Interviewed regarding environmental concerns, care plans, medication destruction, respiratory equipment storage, and infection preventionist designation |
| Licensed Practical Nurse M | Licensed Practical Nurse | Interviewed regarding chemotherapy resident and medication destruction |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication destruction, pharmacist recommendations, respiratory equipment storage, and infection preventionist designation |
| Housekeeper G | Housekeeper | Interviewed regarding resident code status signage |
Inspection Report
Routine
Census: 56
Deficiencies: 10
Date: May 18, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, and infection control.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within reach for dependent residents, failure to revise care plans timely, failure to follow physician orders for weights and catheter care, failure to maintain code status orders, inadequate communication with dialysis center, failure to provide adequate personal hygiene care, improper wheelchair propulsion without foot pedals, failure to maintain proper food temperatures, and lapses in infection prevention and control practices.
Deficiencies (10)
Failure to keep call lights within reach for three residents.
Failure to revise care plans timely for residents with facial hair, edema, and anticoagulant use.
Failure to follow physician orders for weekly weights for one resident.
Failure to obtain complete physician orders for indwelling catheters for three residents.
Failure to obtain code status orders for two residents.
Failure to maintain ongoing communication with dialysis center for one resident.
Failure to provide adequate personal hygiene care including nail and facial hair care for six residents.
Failure to properly propel residents in wheelchairs using foot pedals.
Failure to maintain hot food temperatures at or above 120°F when served to a resident in room trays.
Failure to maintain infection prevention and control practices including hand hygiene and glove use during wound care and incontinence care.
Report Facts
Facility census: 56
Deficiencies cited: 10
Resident count: 3
Resident count: 6
Resident count: 5
Food temperature: 89
Food temperature: 112
Food temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in findings related to call light placement, personal hygiene care, and infection control lapses |
| Director of Nursing | Director of Nursing | Interviewed regarding call light policies, care plan updates, catheter orders, dialysis communication, wheelchair safety, food temperature, and infection control |
| Administrator | Facility Administrator | Interviewed regarding call light policies, care plan updates, catheter orders, dialysis communication, wheelchair safety, food temperature, and infection control |
| LPN H | Licensed Practical Nurse | Interviewed regarding call light use, care plan updates, catheter orders, dialysis communication, wheelchair safety, food temperature, and infection control |
| CMT B | Certified Medication Technician | Interviewed regarding call light use, care plan updates, catheter orders, dialysis communication, wheelchair safety, food temperature, and infection control |
| LPN C | Licensed Practical Nurse | Interviewed regarding catheter orders, dialysis communication, wheelchair safety, and infection control |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and meal service |
| LPN I | Licensed Practical Nurse | Observed and interviewed regarding wound care and hand hygiene |
| LPN C | Licensed Practical Nurse | Observed and interviewed regarding wound care and hand hygiene |
| NA E | Nurse Aide | Observed and interviewed regarding wheelchair propulsion, incontinence care, and infection control |
| NA G | Nurse Aide | Observed and interviewed regarding wheelchair propulsion, incontinence care, and infection control |
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