Cuba Manor Inc

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure five residents (Resident #3, # 5, #9, #37, and #50) out of eight residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene and grooming. The facility census was 62.1. Review of the facility's policy titled Care of Nails (fingers and toes) policy, undated, showed nursing assistants may perform nail care on the residents who are not at risk for complications of infection. The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease (poor circulation). The policy did not provide guidance on when to perform nail care. Review of the facility's policy titled Perineal Care, undated, showed the purpose is to clean the perineum and prevent infection and odor. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to transfer two residents (Residents #3 and #62) out of three sampled residents by mechanical lift in a manner to prevent accidents. The facility census was 62.1. Review of the facility's Mechanical Lift policy, undated, showed to follow the manufacturer's instructions when using any type of lift. The policy showed the purpose is to enable one individual to lift and move a resident safely. The policy did not contain directions or guidance regarding the number of staff required during a mechanical lift transfer. Review of the Mechanical Lift Manual, dated 2022, showed although the company recommends two assistants be used for all lifting preparation and transferring-from and transferring-to procedures, our equipment will permit proper operation by one assistant. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure medications not in use and expired were properly discarded. The facility census was 62.1. Review of the facility's Storage of Medication's Policy, undated, showed no discontinued, outdated or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. Review of the facility's Destruction of Medications Policy, undated, showed two licensed nurses or one licensed nurse and facility pharmacist will destroy all medications, except controlled substances which will require Director of Nursing (DON) supervision. The medications will be placed in a sealable container such as a plastic bag. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to change gloves and wash/sanitize hands during incontinence care for three residents (Resident #3, #18, and #62), and failed to clean a mechanical lift after use for two residents (Resident #3, #62). The facility census was 47.1. Review of the facility's Handwashing policy, undated, showed the policy did not contain direction or guidance on when to perform hand hygiene. The purpose of handwashing is to reduce transmission of organisms from resident to resident, nursing staff to resident, and/or resident to nursing staff. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to promote and facilitate the right of self-determination when staff failed to honor two residents (Resident #33 and #58) preferences to sleep later in the morning for two out of eight sampled residents. The facility census was 62.1. Review of the facility's Resident Rights policy, undated, showed the resident has the right to participate in his/her own care and to be fully respected and adhered to.2. Review of Resident #33's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/08/26, showed staff assessed the resident as cognitively intact. Review of the resident's face sheet, dated 05/15/26, showed the resident is responsible for himself/herself. [...]

Inspectors wroteBased on interviews, and record review, facility staff failed to ensure dental care services were provided as recommended by a dentist for one resident (Resident #4) out of one sampled resident. The facility census was 47.1. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/13/26, showed staff assessed the resident as:-Cognitively intact;-Diagnosed with dental caries, unspecified;-Abnormal mouth tissue, obvious or likely cavities or broken natural teeth, and mouth or facial pain, discomfort or difficulty with chewing. Review of the resident's care plan, revised 05/08/26, showed staff are to assist with dental/oral hygiene needs, and he/she has own teeth in poor condition. Review of the resident's physician's order set (POS), dated May 2026, showed the resident may be seen by dental provider as needed. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide an ongoing activity program designed to meet the resident's interest, mental, and psychosocial well-being for five dependent residents (Resident #11, #13, #20, #29, and #52) out 24 sampled residents. The facility census was 59. 1. Review of the facility's policy titled Resident Activities, dated 03/2012, showed staff were directed to: -The Activity Director (AD) plans and organizes a program of approved activities for residents on a group level and for individuals to meet the needs of the residents; -All staff is responsible for assisting residents to activities of their choice; -An activity program is planned for each resident as a part of their total resident care by the AD; -An individualized program will be implemented for residents unable to participate or attend activities; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure as needed psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) orders were limited to 14 days unless specific duration and clinical rationale were provided for two of five sampled residents (Resident #14 and #45). The facility census was 59. 1. Review of the policies provided by the facility showed they did not contain a psychotropic medication policy. 2. Review of Resident #14's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had inattention and disorganized thinking, but no altered level of consciousness, delusions or behavioral symptoms; -Used antianxiety mediations; -Diagnosis of aphasia (the loss of ability to understand or express speech), Parkinson's Disease, anxiety, depression, bipolar disease, and schizophrenia; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label creams and ointments in a safe and effective manner when staff did not document the open date on the creams and ointments in the treatment carts and failed to discard the expired creams and ointments. The facility census was 59. 1. Review of the facility's Medication Storage policy, undated, showed no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. Each resident must have a space assigned to them that prevents the possibility of a drug for one resident being administered to another. Review of the facility's Medication Destruction policy, undated, showed all medications not returned to the issuing pharmacy will be destroyed. [...]

Inspectors wroteBased on observation, interview and record review, facility staff did not maintain a safe, clean, comfortable and homelike environment, when staff failed to properly maintain residents' rooms, bathroom vanities and furniture. Additionally, facility staff failed to clean and maintain oxygen concentrator filters for two residents (Resident #4 and #26). The facility census was 67. 1. Review of the policies provided by the facility showed no policy for reporting and/or reporting concerns with resident rooms, bathrooms or furniture. 2. Observation on 09/18/23 at 11:37 A.M., showed room [ROOM NUMBER] floor had black marks, stains and a buildup of debris between the tiles. The bathroom vanity had missing paint and a yellow substance on the front and the walls had gouges and black marks. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the care needs for three residents (Residents #22, #29 and #58). The census was 67. 1. Review of the facility's policy, titled Care Planning - Interdisciplinary Team, undated, showed a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment. 2. Review of Resident #22's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/02/23, showed staff assessed the resident as follows: -Cognitively intact; -No dental or oral status concerns. Review of the resident's baseline care plan, dated 08/30/23, showed it did not contain documentation the resident wore dentures. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for six residents (Resident #4, #20, #30, #40, #52, and #53). The facility census was 67. 1. Review of the facility's policy, titled Care Planning - Interdisciplinary Team, undated, showed a comprehensive care plan for each resident is to be developed within seven days of completion of the resident assessment. Review of the policy showed no time frame for revisions of care plans. 2. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/15/23, showed staff assessed the resident as follows: -Cognitively intact; -Required limited assistance from one staff member for personal hygiene and dressing. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to communicate pharmacy recommendations to the physicians of three residents (Resident #30, #34, and #56) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census is 67. 1. Review of the facility's policy, titled Drug Review, undated, showed staff were directed to do the following: -All medications given to each resident will be reviewed on a monthly basis in order to: - Review drug interactions; - Ensure adherence to stop orders; - Ensure accuracy in administration; - Evaluate medications are appropriate to diagnosis; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas; -Problems identified shall be addressed according to need in consultation with the physician. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to destroy discontinued and As Needed (PRN) medications in a timely manner for two residents (Resident #8 and #14). The facility census was 67. 1. Review of the facility's policy titled, Storage of Medications, dated 02/07/2013, showed staff were directed to do the following: -Discontinued medications will be place in a locked cabinet for destruction; -Medications will be destroyed at least weekly; -No discontinued medications may be retained for use. 2. Observation on 09/18/23 at 2:22 P.M., showed the following medications for resident #8 in the medication destruction cabinet of the [NAME] Side Medication Room: -14 capsules (caps.) of 100 milligram (mg) Gabapentin (anticonvulsant) with a discontinued date of 03/22/23; -10 caps. of 100 mg Gabapentin with a discontinued date of 03/22/23; -28 caps. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to to clean and store respiratory equipment and devices in a manner to prevent the spread of infection for four residents (Residents #22, #26, #30 and #40). The facility census was 67. 1. Review of the facility's policy titled, Continuous Pressure Airway Pressure (CPAP) (a machine that uses mild air pressure to keep breathing airways open while you sleep) Administration, dated March 2015, showed no direction for staff in regard to storing the mask in a sanitary manner when not in use. Review of the facility's policy titled, Oxygen Administration, undated, showed staff no direction for staff in regard to oxygen tubing storage when not in use. 2. Review of Resident #22's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/02/23, showed staff assessed the resident as follows: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to accurately code oxygen use for two residents (Resident #4 and #30), chemotherapy (drug treatment that uses powerful chemicals to kill fast-growing cells in the body) for one resident (Resident #20) and Continous Positive Airway Pressure (CPAP), a machine that uses mild air pressure to keep airways open while sleeping, use for one resident (Resident #40). The facility census was 67. 1. Review of the policies provided by the facility showed no Minimum Dat Set (MDS), a federally mandated assessment tool completed by facility staff, policy. 2. Review of Resident #4's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use oxygen. [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for two residents (Resident #29 and #58). The facility census was 67. 1. Review of the facility's policy, titled Care Plan, Temporary, undated, showed staff were directed to do the following: -A temporary care plan will be implemented to meet the new resident's immediate needs; -To assure that the resident's immediate care needs are met and maintained, a temporary care plan will be implemented within 24 hours of admission; -The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI) (assessment used to determine resident care needs) process. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure three residents (Residents #4, #22 and #40), who were unable to complete their own activities of daily living (ADLs) (showering/bathing, dressing, and personal hygiene), received the necessary care and services to maintain good personal hygiene. The facility census was 67. 1. Review of the facility's policy titled, Activities of Daily Living, undated, showed it did not contain direction for staff in regards to how often to change resident's clothing, brush hair, or provide showers. Review of the facility's policy titled, Nails, Care of (Fingers and Toes), undated, showed staff were directed to do the following: -The purpose is to provide cleanliness, comfort, and prevent the spread of infection; [...]

Inspectors wroteBased on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The facility census was 67. 1. Review of the policies provided by facility staff showed no policy for Infection Preventionist training. During an interview on 09/20/23 at 4:31 P.M., the Director of Nursing (DON) said he/she was supposed to be the facility's IP. The previous IP stopped working for the facility on 07/15/22. The DON said he/she went online and signed up for the IP training, but he/she had not started the training because he/she kept getting pulled to the floor to work as a charge nurse. During an interview on 09/21/23 at 11:50 A.M., the Administrator said the facility currently did not have an IP. [...]