Deficiencies (last 7 years)
Deficiencies (over 7 years)
11.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
116% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
66% occupied
Based on a December 2024 inspection.
This facility has shown a decline 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
Annual Inspection
Census: 59
Deficiencies: 6
Date: Dec 11, 2024
Visit Reason
The inspection was conducted as an annual survey of Cuba Manor Inc. to assess compliance with federal and state regulations regarding resident care, medication management, and facility safety.
Findings
The facility was found deficient in providing ongoing activity programs tailored to residents' interests and cognitive abilities, proper management of psychotropic medications including PRN orders, and appropriate labeling and storage of drugs and biologicals. Several residents were observed with eyes closed during activities, and medication orders lacked clinical rationale or exceeded allowed durations.
Deficiencies (6)
F679 Activities Meet Interest/Needs Each Resident. The facility failed to provide an ongoing activity program designed to meet the interests, mental, and psychosocial well-being of five dependent residents. Observations showed residents often with eyes closed during activities and staff did not ensure engagement.
F758 Free from Unnecessary Psychotropic Meds/PRN Use. Facility staff failed to ensure psychotropic medication orders were limited to 14 days unless clinically justified. Two residents had PRN orders exceeding 14 days without documented rationale, and medication administration records lacked documentation of use.
F761 Label/Store Drugs and Biologicals. Facility staff failed to store and label creams and ointments in a safe and effective manner. Observations found multiple opened and undated topical medications, some expired, and failure to discard expired products as per policy.
A2010 Oxygen Storage. Oxygen storage did not comply with NFPA 99, 1999 edition. Safety caps were not intact and cylinders were not properly supported by collars or stable carts.
A2020 Fire Alarm System-Inspections/Certifications. Complete fire alarm systems lacked required annual inspections and written certifications by qualified service representatives.
A2034 Sprinkler System-Test/Maintain. Sprinkler system maintenance and testing requirements were not met as per regulations effective August 27, 2007.
Report Facts
Facility census: 59
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Young | Administrator | Signed inspection report and plan of correction |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding psychotropic medication administration and activity engagement |
| Director of Nursing | Director of Nursing | Interviewed regarding staff responsibilities for resident activities and medication order review |
Inspection Report
Life Safety
Census: 59
Capacity: 90
Deficiencies: 6
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, including testing and maintenance of fire alarm and sprinkler systems, as well as oxygen cylinder storage safety.
Findings
The facility failed to maintain proper documentation and qualifications for fire alarm system inspections and testing. Deficiencies were also found in sprinkler system maintenance, including missing monthly backflow prevention inspections and incomplete trip testing of the dry pipe valve. Additionally, oxygen cylinders were not stored securely or in compliance with fire safety standards.
Deficiencies (6)
K345 Fire Alarm System - The facility failed to provide complete and verifiable documentation for semi-annual inspection and testing by qualified personnel. The facility lacked a process to verify qualifications of contracted service technicians.
K353 Sprinkler System - The facility failed to inspect and test the dry pipe sprinkler system and backflow prevention assembly monthly as required. Records did not contain documentation of required inspections and tests.
K923 Gas Equipment - Oxygen cylinders were not stored securely or separated from combustibles as required. Wooden shelves in oxygen storage rooms were combustible and keys to storage rooms were accessible to unauthorized persons.
A4055 Safe/Effective Medication System - The facility failed to maintain a safe and effective medication system as evidenced by a Class II deficiency.
A4064 Medication Storage - Medications were not stored at appropriate temperatures or in a secure manner, including failure to lock refrigerated medications and separate discontinued medications.
A4101 Activity Program - The facility failed to designate an employee responsible for the activity program and did not provide planned activity programs for residents, resulting in a Class III deficiency.
Report Facts
Facility census: 59
Total capacity: 90
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Spring | Administrator | Signed the inspection report and plan of correction |
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
Annual Inspection
Census: 67
Deficiencies: 9
Date: Sep 21, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Cuba Manor Inc.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accuracy of resident assessments, comprehensive person-centered care planning, drug regimen review, infection prevention and control, and other regulatory requirements. Multiple residents were identified at risk due to these deficiencies.
Deficiencies (9)
F584 Safe/Clean/Comfortable/Homelike Environment: Facility staff failed to maintain residents' rooms, bathrooms, and furniture in a safe, clean, and comfortable condition as evidenced by paint chipping, stains, debris, and unclean oxygen concentrator filters. The facility census was 67.
F641 Accuracy of Assessments: Facility staff failed to accurately code oxygen use, chemotherapy, and CPAP use for multiple residents, and no Minimum Data Set (MDS) policy was provided. The facility census was 67.
F655 Baseline Care Plan: Facility staff failed to complete baseline care plans within 48 hours of admission for two residents and did not direct staff regarding use of CPAP or oxygen treatments.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to ensure residents had complete, accurate, and individualized care plans addressing medical, nursing, and psychosocial needs. The census was 67.
F657 Care Plan Timing and Revision: Facility failed to develop comprehensive care plans within seven days of assessment and failed to revise care plans timely for six residents. The facility census was 67.
F677 ADL Care Provided for Dependent Residents: Facility failed to provide necessary care for three residents unable to complete activities of daily living, including hygiene and grooming. The facility census was 67.
F756 Drug Regimen Review, Report Irregular, Act On: Facility failed to review drug regimens monthly and failed to destroy discontinued medications timely for two residents. The facility census was 67.
F880 Infection Prevention & Control: Facility failed to establish and maintain an infection prevention program, including proper storage of respiratory equipment and staff training. The facility census was 67.
F882 Infection Preventionist Qualifications/Role: Facility failed to designate a qualified infection preventionist and provide required training. The facility census was 67.
Report Facts
Facility census: 67
Discontinued medications: 14
Discontinued medications: 10
Discontinued medications: 28
Discontinued medications: 28
Discontinued medications: 19
Discontinued medications: 8
Discontinued medications: 29
Discontinued medications: 90
Discontinued medications: 79
Discontinued medications: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Young | Administrator | Signed deficiency statement and plan of correction |
| Licensed Practical Nurse (LPN) A | Interviewed regarding environmental concerns, oxygen and chemotherapy treatments, baseline care plans, and medication destruction | |
| Assistant to the Director of Nursing (ADON) | Interviewed regarding environmental concerns, oxygen and chemotherapy treatments, MDS assessments, care plans, and medication destruction | |
| Floor Technician K | Interviewed regarding environmental concerns and maintenance | |
| Certified Nurse Aide (CNA) B | Interviewed regarding documentation of maintenance issues and resident care | |
| Director of Nursing (DON) | Interviewed regarding care plans, medication destruction, infection prevention, and staff training | |
| Housekeeper G | Interviewed regarding resident code status signage | |
| Licensed Practical Nurse (LPN) M | Interviewed regarding chemotherapy treatments and medication destruction |
Inspection Report
Life Safety
Census: 67
Capacity: 90
Deficiencies: 4
Date: Sep 21, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code provisions of the National Fire Protection Association (NFPA) 2012 edition, focusing on hazardous areas, sprinkler system maintenance, smoke barriers, and electrical systems.
Findings
The facility failed to maintain fire resistance ratings in hazardous areas due to unsealed gypsum board penetrations, did not maintain a supply of spare sprinklers, failed to maintain smoke barrier walls to prevent smoke passage, and failed to inspect and test essential electrical systems adequately.
Deficiencies (4)
K321 Hazardous Areas - The facility staff failed to maintain fire resistance ratings by allowing gypsum board penetrations that reduced fire resistance in hazardous areas.
K353 Sprinkler System - The facility failed to maintain a supply of spare sprinklers and did not properly inspect and maintain the sprinkler system components.
K372 Smoke Barrier - The facility failed to maintain smoke barrier walls to ensure smoke tightness, allowing smoke to pass through unsealed penetrations.
K918 Electrical Systems - The facility failed to inspect and test essential electrical systems and maintain documentation of inspections and testing.
Report Facts
Facility census: 67
Facility capacity: 90
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 7
Date: May 18, 2022
Visit Reason
The document is a Plan of Correction submitted by Cuba Manor following a survey conducted on 05/18/2022 to address cited deficiencies.
Findings
The facility was found deficient in multiple areas including reasonable accommodations for residents' needs, care plan revisions, infection control, clinical records accuracy, accident prevention, and food temperature management. Specific residents were identified with unmet care needs and staff failed to follow required procedures.
Deficiencies (7)
F558 Reasonable Accommodations Needs/Preferences: Facility staff failed to provide reasonable accommodations to meet the needs of dependent residents by not keeping call lights within reach for three residents.
F657 Care Plan Timing and Revision: Facility staff failed to revise care plans for five residents with appropriate interventions and assessments.
F658 Services Provided Meet Professional Standards: Facility staff failed to provide care consistent with professional standards including failure to follow physician orders and maintain communication with dialysis center.
F677 ADL Care Provided for Dependent Residents: Facility staff failed to ensure six residents received necessary care and services to maintain good personal hygiene.
F689 Free of Accident Hazards/Supervision/Devices: Facility staff failed to ensure residents' environment remained free of accident hazards and did not properly supervise or assist five residents in wheelchairs.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: Facility staff failed to maintain correct serving temperatures for hot foods and did not adequately warm residents' meals.
F880 Infection Prevention & Control: Facility staff failed to maintain an effective infection prevention program, including hand hygiene and glove use, affecting multiple residents.
Report Facts
Facility census: 56
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Mentioned in interviews regarding call light placement and infection control | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding call light use, care plan revisions, and infection control |
| Administrator | Administrator | Interviewed regarding call light placement and care plan updates |
| Licensed Practical Nurse (LPN) H | Licensed Practical Nurse | Interviewed regarding call light use and care plan updates |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding food temperature and care plan updates |
| Licensed Practical Nurse (LPN) C | Licensed Practical Nurse | Interviewed regarding care plan updates and catheter care |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding food temperature and dietary procedures |
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 |
Inspection Report
Life Safety
Census: 56
Capacity: 90
Deficiencies: 5
Date: May 18, 2022
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety regulations and hazardous area protections at Cuba Manor Inc.
Findings
The facility failed to ensure hazardous areas had self-closing doors, sprinkler system maintenance was deficient with unsealed gaps around sprinkler heads, corridor doors did not resist smoke passage, smoking regulations were not properly enforced, and oxygen storage areas were unsecured. These deficiencies had the potential to affect all occupants in multiple smoke zones.
Deficiencies (5)
K321 Hazardous Areas - The facility failed to ensure doors to hazardous areas were self-closing, affecting one out of five smoke zones.
K353 Sprinkler System - The facility failed to ensure sprinkler escutcheon plates covered gaps tightly, and holes and penetrations through ceilings were unsealed, affecting all occupants in five smoke zones.
K363 Corridor Doors - Doors leading to corridors did not resist smoke passage or latch properly, affecting occupants in two smoke zones.
K741 Smoking Regulations - The facility failed to maintain designated smoking areas free from fire hazards and cigarette waste, affecting occupants in two smoking areas.
K923 Gas Equipment - The facility failed to secure oxygen storage areas, allowing unauthorized access and improper storage of combustible materials, affecting occupants in two smoke zones.
Report Facts
Census: 56
Total Capacity: 90
Inspection Report
Routine
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 2
Date: Nov 6, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess infection prevention and control compliance related to COVID-19 protocols.
Findings
The facility was found to be in compliance with some infection control requirements but failed to meet infection control protocols related to staff wearing facemasks, hand hygiene, and proper PPE storage and use. Deficiencies were noted in staff adherence to CDC guidelines and facility policies.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to follow infection control protocols for COVID-19, including staff failing to wear facemasks, maintain social distancing, perform hand hygiene, and properly store PPE.
A4085 Infection Control/Communicable Disease: The facility did not meet infection control requirements for reporting communicable diseases as required by Missouri Department of Health regulations.
Report Facts
Facility census: 56
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Young | Administrator | Signed the report and plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Abbreviated Survey
Census: 65
Deficiencies: 2
Date: Sep 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess infection prevention and control compliance related to communicable diseases.
Findings
The facility was found to be in compliance with several infection control requirements but failed to meet the annual review requirement of the infection prevention and control program as evidenced by staff failing to follow infection control guidelines including hand hygiene and glove use.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to conduct an annual review of its infection prevention and control program as staff did not follow infection control guidelines including proper hand hygiene and glove use during resident care.
A4085 Infection Control/Communicable Disease: The facility did not meet the requirement to report communicable diseases to the state division within seven days as required by Missouri regulations.
Report Facts
Facility census: 65
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Young | Administrator | Signed the deficiency statement and plan of correction |
Inspection Report
Routine
Deficiencies: 0
Date: May 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 69
Deficiencies: 3
Date: May 31, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding bedrails and resident safety, including entrapment risk assessments and regular inspections of bed frames, mattresses, and bed rails.
Findings
The facility failed to complete required entrapment assessments for residents using bed mobility devices and did not conduct regular inspections of bed frames, mattresses, and bed rails to identify possible entrapment areas. Staff were unaware of the need to complete these assessments and inspections.
Deficiencies (3)
F700 Bedrails: The facility failed to complete entrapment assessments for five residents using mobility devices, risking resident safety. Staff did not follow manufacturers' recommendations or facility policies regarding bedrail installation and maintenance.
F909 Resident Bed: The facility failed to complete and document regular inspections of all bed frames, mattresses, and bed rails to identify possible entrapment areas for five residents. Staff were unaware of the requirement to complete these inspections.
A4073 Protective Oversight, Voluntary Leave: The facility did not have adequate procedures to ensure protective oversight and supervision for residents on voluntary leave, including procedures to inquire about residents' whereabouts and estimated length of absence.
Report Facts
Facility census: 69
Residents cited for deficiencies: 5
Date of survey completion: May 31, 2019
Plan of Correction completion date: Jul 12, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Corbett | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding resident use of halo bars and entrapment assessments |
| Director of Nursing | Director of Nursing | Interviewed regarding staff completion of entrapment assessments |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding inspections of bed frames and bed rails |
Inspection Report
Life Safety
Census: 69
Capacity: 90
Deficiencies: 5
Date: May 31, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations, focusing on fire drills, oxygen storage, and gas equipment safety.
Findings
The facility failed to conduct required fire drills for February and April 2019 and did not meet fire drill documentation requirements. The facility also failed to properly secure and separate oxygen cylinders and did not provide adequate staff training on medical gas handling and storage.
Deficiencies (5)
K712 Fire Drills: Facility staff failed to conduct fire drills for February and April 2019 and did not meet documentation requirements for fire drills conducted between June 2018 and May 2019.
K923 Oxygen Storage: Facility failed to adequately store and secure oxygen cylinders, with full and empty cylinders not properly separated and one full cylinder unsecured.
K926 Gas Equipment Training: Facility staff did not receive continuing education or training on the handling and safety of medical gases and cylinders, posing a fire risk.
A1036 Oxygen Storage Room: The oxygen storage room was not surrounded by one-hour rated construction with proper ventilation as required.
A2061 Fire Drill Requirements: The facility did not conduct the minimum required twelve fire drills annually, including unannounced drills and simulated resident evacuations.
Report Facts
Facility census: 69
Facility capacity: 90
Fire drills missed: 2
Fire drills required annually: 12
Fire drills required quarterly per shift: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaune Corbett | Administrator | Signed the report and mentioned in plan of correction |
| Maintenance Supervisor | Interviewed regarding fire drills and oxygen storage; name not fully provided | |
| Director of Nursing | Interviewed regarding oxygen storage training and fire drill responsibilities; name not fully provided |
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 8
Date: Jun 22, 2018
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including admissions policy, accuracy of assessments, baseline care plans, activities, respiratory care, and psychotropic medication use. Several residents' records and care plans were incomplete or inaccurate, and the facility failed to ensure proper documentation and care standards.
Deficiencies (8)
F620 Admissions Policy: The facility failed to ensure the admission policy did not require residents to waive liability for loss or damage to personal property. This affected six of 18 sampled residents and had potential to affect all residents.
F641 Accuracy of Assessments: Facility staff did not code the Minimum Data Set (MDS) correctly for two residents. Staff failed to assess and document pressure ulcers and wounds accurately.
F655 Baseline Care Plan: Facility staff failed to complete baseline care plans within 48 hours of admission for three of five sampled new admissions. Documentation and signatures were missing.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to complete comprehensive care plans timely for three residents and did not ensure care plans were updated with measurable goals and interventions.
F677 ADL Care Provided for Dependent Residents: Facility staff failed to bathe four residents to meet hygiene needs. The facility census was 74.
F679 Activities Meet Interest/Needs Each Resident: Facility failed to provide ongoing activity programs meeting residents' interests for three sampled residents. Weekend and evening activities were not provided for all residents.
F695 Respiratory/Tracheostomy Care and Suctioning: Facility failed to ensure cleaning and disinfecting of CPAP equipment for one resident. The facility census was 74.
F758 Free from Unnec Psychotropic Meds/PRN Use: Facility failed to obtain stop dates for PRN psychotropic medications for six residents. Documentation for rationale and duration was missing.
Report Facts
Facility census: 74
Sampled residents: 18
Sampled new admissions: 5
Residents with incomplete baseline care plans: 3
Residents with missing PRN stop dates: 6
Inspection Report
Life Safety
Census: 74
Capacity: 90
Deficiencies: 3
Date: Jun 22, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and electrical system safety requirements at Cuba Manor Inc.
Findings
The facility failed to meet applicable provisions of the 2012 Life Safety Code related to electrical receptacles in resident care rooms and night lights in resident bathrooms. Deficiencies included incomplete testing and certification of electrical receptacles and lack of night lights in resident bathrooms.
Deficiencies (3)
K914 Electrical Systems - Maintenance and Testing: Facility staff failed to assess electrical receptacles in resident care rooms for physical integrity, grounding circuit continuity, polarity, and retention force, posing increased fire and electrical injury risk. The facility census was 74 with a capacity of 90.
A1133 Electrical System-Test/Certify per Code: A qualified electrician did not certify the entire electrical system as compliant with the National Electrical Code, referencing the K914 deficiency.
A3033 Night Lights Provided: Facility staff failed to provide night lights in all resident bathrooms, including all four centralized shower rooms, affecting all residents.
Report Facts
Facility census: 74
Facility capacity: 90
Inspection Report
Plan of Correction
Census: 78
Deficiencies: 1
Date: Jan 11, 2018
Visit Reason
The inspection was conducted to evaluate compliance with notification requirements following a resident fall and to assess the facility's adherence to policies regarding notifying responsible parties of significant changes or incidents.
Findings
The facility failed to notify the responsible party of a resident's fall and condition change as required by regulation. Staff interviews and record reviews confirmed the lack of notification despite the resident being assessed at risk for falls.
Deficiencies (1)
19 CSR 30-85.042(80) Notify Responsible Party-Change in Condition: Facility staff failed to immediately notify the resident's responsible party after the resident experienced a fall and condition change.
Report Facts
Facility census: 78
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