Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0620

Level of harm – Potential for minimal harm

Residents Affected – Many

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a
condition of admission; and must tell residents what care they do not provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to ensure the admission policy
did not require the resident to waive potential facility liability for loss or damage to
personal property for six out of 18 sampled residents (Residents #4, #44, #46, #62, #66,
and #71). This had the potential to affect all facility residents. The census was 74.
1. Review of Resident #4’s medical record, showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s Consents and Authorizations form, showed the following:
-The resident agrees for the facility to maintain his/her personal laundry, understands
commercial grade equipment is used for laundering, and releases the facility from any
responsibility for damage to personal clothing;
-The resident agrees for the facility to provide basic cable television service, but
releases the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the resident;
-Dated 9/1/16.
2. Review of Resident #44’s medical record, showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s Consents and Authorizations form, showed the following:
-The resident agrees for the facility to maintain his/her personal laundry, understands
commercial grade equipment is used for laundering, and releases the facility from any
responsibility for damage to personal clothing;
-The resident agrees for the facility to provide basic cable television service, but
releases the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the resident’s Responsible Party;
-Dated 9/21/16.
3. Review of Resident #46’s medical record, showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s Consents and Authorizations form, showed the following:
-The resident agrees for the facility to maintain his/her personal laundry, understands
commercial grade equipment is used for laundering, and releases the facility from any
responsibility for damage to personal clothing;
-Signed by the resident’s Responsible Party;
-Dated 11/28/15.
4. Review of Resident #62’s medical record, showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s Consents and Authorizations form, showed the following:
-The resident agrees for the facility to maintain his/her personal laundry, understands
commercial grade equipment is used for laundering, and releases the facility from any
responsibility for damage to personal clothing;
-Signed by the resident’s Responsible Party;
-Dated 1/2/17.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0620

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 1)
5. Review of Resident #66’s medical record, showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s Consents and Authorizations form, showed the following:
-The resident agrees for the facility to maintain his/her personal laundry, understands
commercial grade equipment is used for laundering, and releases the facility from any
responsibility for damage to personal clothing;
-Signed by the resident’s Responsible Party;
-Dated 2/2/17.
6. Review of Resident #71’s medical record, showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s Consents and Authorizations form, showed the following:
-The resident agrees for the facility to maintain his/her personal laundry, understands
commercial grade equipment is used for laundering, and releases the facility from any
responsibility for damage to personal clothing;
-The resident agrees for the facility to provide basic cable television service, but
releases the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the resident’s Responsible Party;
-Dated 9/22/17.
7. During an interview on 6/22/18 at 5:30 P.M., the Social Worker said the current
admission packet was put together by Corporate Office. She reviews the section labeled
Social Services Section with new residents and their families/responsible party. The
Consents and Authorization page is part of the current admission packet. The third
paragraph discusses the facility doing the resident’s laundry. This paragraph asks the
resident to release the facility from any responsibility for damage to personal clothing.
The fourth paragraph discusses the facility providing basic cable television service. This
paragraph asks the resident to release the facility from any responsibility for damage to
the personal television set as a result of the television cable installation and
connection. She does not know why the residents are asked to waive the facility’s
responsibility for his/her personal items brought into the facility. She is aware that the
facility cannot ask the resident to waive the facility’s responsibility for their personal
belongings. Upon admission, the facility assumes responsibility for care of
the resident’s belongings. She does not know why the Corporate Office put that in the
admission packet.
8. During an interview on 6/22/18 at 5:40 P.M. the Administrator said the Social Worker
and the Business Office Manager review the admission packet with the new resident and
family/responsible party before admission. The packet is put together by Corporate Office.
The admission packet contains the Consents and Authorization page. She does not know why
the residents are asked to release the facility from any responsibility for damage to
personal clothing while during the laundering process. She would have to contact the
corporate lawyer to understand their intentions. She does not know why the residents are
asked to release the facility from any responsibility for damage to the personal
television set as a result of the television cable installation and connection. She would
have to contact the corporate lawyer to understand their intentions.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, staff interview and record review, facility staff did not code the
Minimum Data Set (MDS) according to the Resident Assessment Instrument (RAI) manual for
two resident’s (Resident #10, and #31) the facility census is 74.
1. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated (MONTH)
(YEAR), showed the following definitions:
-Stage 1 pressure injury is intact skin with localized area of non-blanchable (when you
press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness).
Presence of blanchable [DIAGNOSES REDACTED] changes in sensation, temperature, or firmness
may precede visual changes;
-Stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis (the
thick layer of living tissue below the top layer of skin that forms the true skin). The
wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new
connective tissue), slough (dead tissue in the process of separating from the body which
is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or
falls off from health skin) are not present;
-Stage 3 pressure injury is a full thickness loss of skin, where adipose (fat) is visible
in the ulcer and granulation tissue and rolled wound edges are often present. Slough and
eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue
damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a
thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not
exposed;
-Stage 4 pressure injury is a full-thickness skin and tissue loss with exposed or directly
palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or
eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges,
undermining and or tunneling often occur. Depth varies by location;
-Unstageable pressure injury is a full thickness skin and tissue loss in which the extent
of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or
eschar;
-Deep Tissue Pressure Injury is an intact or non-intact skin with localized area of
persistent non-intact skin with localized area of persistent non-blanchable deep red,
maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or
blood filled blister. This injury results from intense and/or prolonged pressure and shear
forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual
extent of tissue injury, or may resolve without tissue loss. If necrotic tissue,
subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures
are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or
stage 4 pressure injury).
2. Review of the Resident Assessment Instrument (RAI) manual, dated 10/1/17, directs
facilities that Stage 2 pressure ulcers by definition have partial-thickness loss of the
dermis. Granulation tissue, slough or eschar are not present in Stage 2 pressure ulcers.
Therefore, Stage 2 pressure ulcers should not be coded as having granulation, slough or
eschar tissue.
3. Review of Section M (Skin Condition) on the MDS assessment showed staff assessed
Resident # 10 not to be at risk for pressure ulcers and without current, unhealed wounds
in the quarterly assessment dated [DATE].
Review of the Braden Scale (a tool for predicting pressure ulcer risk) dated 12/19/17,
showed staff assessed the resident to be at risk for developing pressure ulcers.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
Review of the nurse’s notes showed the following:
-10/21/17 one centimeter (cm) by one cm blackened area on left outer ankle with [DIAGNOSES
REDACTED];
-12/13/17 wound left outer ankle improving this week. Skin integrity and pressure relief
interventions in place.
During an interview on 6/22/18, at 4:12 P.M., the MDS coordinator (MDSC) said he/she does
not know why the resident was not coded to have a pressure ulcer and to be at risk for
developing pressure ulcers. The MDSC said it must have been an oversight.
4. Review of Resident #31’s significant change MDS, a federally mandated assessment tool,
dated 4/16/18, showed staff documented the following:
-Severe Cognitive impairment;
-One Stage 2 Pressure Ulcer developed 4/12/18, granulation tissue is the most severe
tissue type;
-Dependent with the assistance of two or more staff members for bed mobility, transfers,
toilet use, personal hygiene, and bathing;
-Use of a wheelchair.
(Stage 2 pressure ulcers can not have granulation tissue present).
Review of the resident’s admission assessment, dated 4/12/18, showed staff documented the
resident with an open area on the resident’s coccyx area.
Observation on 6/21/18, at 11:52 A.M., showed the resident with a dressing dated 6/21/18
on his/her coccyx.
During an interview on 6/21/18, at 11:52 A.M., certified nurse assistant (CNA) C said the
resident has a small open area on his/her coccyx.
During an interview on 6/21/18, at 12:05 P.M., licensed practical nurse (LPN) D said the
resident has an open area on the coccyx. He/She said the wound is on the inner buttocks in
the coccyx area.
Observation on 6/21/18, at 3:49 P.M., showed the resident with a dime sized open area
longer than wide on his/her coccyx, along the sacral bony prominence. Observation showed
the wound bed with yellow slough, thin line of granulation tissue around the edges of the
wound bed, and a dark black eschar area in the center. Observation showed the periwound
had purple nonblanchable tissue around the wound.
During an interview on 6/21/18, at 3:49 P.M., registered nurse (RN) E said he/she
classified the area as moisture associated [MEDICAL CONDITION]. He/She said the wound
measures 1.4 cm in length, 0.8 cm in width, and 0.3 cm in depth. He/She said the wound had
3% eschar, 80% slough, and 27 % granulation tissue, and the periwound purple area is
nonblanchable.
During an interview on 6/21/18, at 3:55 P.M., LPN D said the open area is a pressure ulcer
from the hospital, and it is documented on the admission assessment. He/She said he/she is
not sure if the wound is on the care plan, but with the tissue present, the wound is at
least a Stage 3 pressure ulcer.
5. During an interview on 6/22/18, at 4:12 P.M., the MDS coordinator (MDSC) said he/she
does not know the RAI manual guidance on granulation tissue or pressure compared to
arterial wounds. He/she said he/she has to go off of what the wound nurse documents.
He/She said all staff that complete the MDS’s are expected to complete the MDS according
to the RAI manual.
During an interview on 6/22/18, 4:12 P.M., the director of nursing (DON) said he/she did
not know Resident #31 has an open wound. He/She said wounds should be staged according to
the RAI manual, and the NPUAP guidelines.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interview and record review, facility staff failed to complete a baseline
care plan within 48 hours of admission for three residents (Resident #67, #74, and #178)
out of five sampled new admissions. Facility staff also failed to document the baseline
care plan was reviewed with the resident or responsible party for five residents (Resident
#65, #67, #74, #178, and #300) out of five sampled new admissions. The facility census was
74.
1. Review of the facility’s Baseline Care Plan form, undated, directs the staff in the
baseline care plan meeting checklist to:
-Print completed baseline care plan;
-Make resident a copy of current physician orders;
-Obtain a copy of the therapy plan of care if applicable;
-Review baseline care plan, physician orders, and therapy plan of care with resident and
resident representative within 48 hours. Provide copies of all documents;
-Retain baseline care plan with signatures and file per facility protocol;
-Mark not applicable if unable to review and explain in space provided.
The facility did not provide a policy for Baseline Care Plans.
2. Review of Resident #178’s admission Minimum Data Set (MDS), a federally mandated
assessment tool, dated 6/7/18, showed staff documented:
-Admission to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Severe cognitive impairment;
-Sometimes understood/understands;
-Poor appetite 2-6 days;
-Verbal behaviors and other behavioral symptoms not directed at others 1-3 days;
-Behaviors significantly interfere with the resident’s care, and with the resident’s
participation in activities or social interaction;
-Behaviors significantly intrude on the privacy or activity of others, and disrupt
care/living environment;
-Rejection of care 1-3 days;
-Always incontinent of bowel and bladder;
-Signs of possible pain present in the last 5 days: non-verbal sounds, vocal complaints,
and facial expressions;
-Fall prior to admission, one fall without injury since admission, and one fall with
injury since admission;
-At risk for pressure ulcers;
-Antianxiety and opioid medication every day;
-Hospice care;
-Limited physical assistance of one staff member for ambulation, locomotion, and eating;
-Extensive assistance of two staff members for bed mobility, transfers, dressing, toilet
use, and bathing;
-Balance unsteady, only able to stabilize with human assistance;
-Use of a wheelchair.
Review of the resident’s baseline care plan, dated 6/19/18, showed the staff completed the
base line care plan 20 days after the resident’s admission. Additional review showed staff

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
did not complete the baseline care plan meeting checklist, or document why the care plan
meeting did not occur.
The Baseline Care Plan did not contain the resident or resident’s representative
signature, or a date staff reviewed the 48 hour care plan with the resident and/or
resident’s representative.
Review of the resident’s medical record showed it did not contain documentation of a
review of the baseline care plan with the resident or the resident’s representative.
3. Review of Resident #65’s, admission MDS, dated [DATE], showed staff documented:
-Admission to the facility on [DATE];
-Cognitively intact;
-Limited physical assistance of one staff member for bed mobility, transfers, locomotion,
and dressing;
-Extensive physical assistance of one staff member for bathing;
-Balance not steady;
-Use of a walker or wheelchair;
-Oxygen use;
-At risk for development of pressure ulcers.
Review of the resident’s Baseline Care Plan, dated 5/19/18, showed staff did not complete
the baseline care plan meeting checklist, or document why the care plan meeting did not
occur. The Baseline Care Plan did not contain the resident or resident representative
signature, or a date staff reviewed the 48 hour care plan with the resident and/or
resident’s representative.
Review of the resident’s medical record showed it did not contain documentation of a
review of the baseline care plan with the resident or the resident’s representative.
4. Review of Resident #67’s, admission Minimum Data Set (MDS), a federally mandated
assessment, dated 06/07/18, showed staff assessed the resident as:
-Admission to the facility on [DATE] ;
-Cognitively intact;
-Limited physical assistance of one staff member for bed mobility, transfers, locomotion,
dressing, toileting, personal hygiene, and bathing;
-Always continent of bowel and bladder;
-Use of a walker or wheelchair;
-[DIAGNOSES REDACTED].
-Takes pain medication as needed for occasional pain of 4 out of 10 on the pain scale;
-Had one fall prior to admission with a major injury;
-During the seven day look back period took seven days of antibiotics and seven days of an
opiod.
Review of the resident’s Baseline Care Plan, dated 06/07/18, showed staff did not complete
the baseline care plan meeting checklist, or document why the care plan meeting did not
occur. The Baseline Care Plan did not contain the resident or resident representative
signature, or a date the staff reviewed the 48 hour care plan with the resident and/or
resident’s representative.
Review of the resident’s medical record showed it did not contain documentation of a
review of the baseline care plan with the resident or the resident’s representative.
5. Review of Resident #74’s admission MDS dated [DATE], showed staff assessed the resident
as:
-Cognitively intact;
-Extensive physical assistance of one staff member for bathing;
-Limited physical assistance of one staff member for bed mobility, transfers, locomotion,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
dressing, toileting, and personal hygiene;
-Independent with set up help for eating;
-Limited range of motion (ROM) on one side of upper and lower extremities;
-[DIAGNOSES REDACTED].
-Receives pain medication as needed for occasional pain of four out of ten on the pain
scale;
-One fall with major injury;
-During the seven day look back period took insulin for seven days, an antidepressant for
seven days, and an opiod for four days.
Review of the resident’s chart showed the base line care plan as completed, but not dated.
Additional review showed staff did not complete the baseline care plan meeting checklist,
or document why the care plan meeting did not occur.
The Baseline Care Plan did not contain the resident or resident’s representative
signature, or a date the staff reviewed the 48 hour care plan with the resident and/or
resident’s representative.
Review of the resident’s medical record showed it did not contain documentation of a
review of the baseline care plan with the resident or the resident’s representative.
6. Review of Resident #300, entry tracking MDS, dated [DATE], showed staff documented the
resident’s admitted to the facility as 6/12/18.
Review of the resident’s Baseline Care Plan, dated 6/11/18, showed staff did not complete
the baseline care plan meeting checklist, or document why the care plan meeting did not
occur. The Baseline Care Plan did not contain the resident or resident representative
signature, or a date staff reviewed the 48 hour care plan with the resident and/or the
resident’s representative.
Review of the resident’s medical record did not contain documentation of a review of the
baseline care plan with the resident or the resident’s representative.
7. During an interview on 6/22/18, at 9:14 A.M., licensed practical nurse (LPN) A said
charge nurses complete the baseline care plan on admission. He/She said if they are not
completed on the first shift they are passed on. He/She said they are supposed to be
completed by 48 hours after admission. He/She is not sure who reviews to make sure it is
completed, or why they are not completed.
During an interview on 6/22/18, at 4:12 P.M., the MDS coordinator said baseline care plans
are expected to be completed by the charge nurses within 24-48 hours. He/She said the
director of nursing (DON) is responsible to make sure all the baseline care plans are
completed.
During an interview on 6/22/18, at 5:00 P.M., the director of nursing (DON) said the
admitting nurse is expected to complete the 48 hour care plan and pass it on if it is not
completed to the next shift, and file the document in the resident’s medical record.
He/She said he/she is unable to locate the baseline care plans for Resident’s #67, #74,
and #178. He/She does not know why the baseline care plans completed within 48 hours are
not in the resident’s medical records.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility staff failed to complete a comprehensive

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
care plan for one resident (Resident #178), and failed to develop measurable goals and
interventions for comprehensive care plans for two residents (Resident #31, #50). The
facility census was 74.
1. Review of the Resident Assessment Instrument (RAI) manual, dated 10/1/17, directs staff
to:
-The Admission assessment is a comprehensive assessment for a new resident and, under some
circumstances, a returning resident that must be completed by the end of day 14;
-If the RAI (Minimum Data Set (MDS) and Care Area Assessments (CAAs)) is not completed
until the last possible date (the end of calendar day 14 of the stay), many of the
appropriate care area issues, risk factors, or conditions may have already been
identified, causes may have been considered, and a preliminary care plan and related
interventions may have been initiated. A complete care plan is required no later than 7
days after the RAI is completed (within 21 days of admission).
2. Review of the facility’s policy Care Plan Comprehensive, dated (MONTH) (YEAR), directs
staff:
-An individualized comprehensive care plan that includes measurable goals and time frames
will be developed to meet the resident’s highest practicable physical, mental, and
psychosocial well-being;
-The comprehensive care plan will be based on a thorough assessment that includes, but is
not limited to, the MDS;
-Assessment of each resident is ongoing process and the care plan will be revised as
changes occur in the resident’s condition;
-A well developed care plan will be oriented to:
a. Preventing avoidable declines in functioning (unless another goal takes precedence
i.e. palliative care);
b. Managing risk factors to the extent possible;
c. Addressing ways to preserve and build upon resident strengths;
d. Applying current standards of practice in the care planning process;
e. Evaluating treatment of [REDACTED].
f. Respecting the resident’s right to decline treatment;
g. Offering alternative treatments, as applicable;
h. Using an appropriate interdisciplinary approach to care plan development to improve
the resident’s functional abilities;
i. Involving resident, resident’s family and other resident representatives as
appropriate;
j. Assessing and planning for care to meet the resident’s medical, nursing, mental and
psychosocial needs;
k. Involving the direct care staff with the care planning process relating to the
resident’s expected outcomes;
l. Addressing additional care planning areas that are relevant to meeting the resident’s
needs in the long-term care setting;
-The comprehensive care plan is developed within seven days of the completion of the
resident’s comprehensive assessment, MDS and CAAs;
-The interdisciplinary care plan team is responsible for the periodic review and updating
of care plans when a significant change in the residents condition has occurred, at least
quarterly, and when changes occur that impact the resident’s care .
3. Review of Resident #178’s admission MDS, dated [DATE], showed staff documented the
following:
-Admission to the facility on [DATE];
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
-[DIAGNOSES REDACTED].
-Severe cognitive impairment;
-Sometimes understood/understands;
-Poor appetite 2-6 days;
-Enjoys listening to music, being around animals, doing things with groups of people, and
participating in favorite activities;
-Verbal behaviors and other behavioral symptoms not directed at others 1-3 days;
-Behaviors significantly interfere with the resident’s care, and with the resident’s
participation in activities or social interaction;
-Behaviors significantly intrude on the privacy or activity of others, and disrupt
care/living environment;
-Rejection of care 1-3 days;
-Always incontinent of bowel and bladder;
-Signs of possible pain present in the last 5 days: non-verbal sounds, vocal complaints,
and facial expressions;
-Fall prior to admission, one fall without injury since admission, and one fall with
injury since admission;
-At risk for pressure ulcers;
-Antianxiety and opioid medication every day;
-Hospice care;
-Limited physical assistance of one staff member for ambulation, locomotion, and eating;
-Extensive assistance of two staff members for bed mobility, transfers, dressing, toilet
use, and bathing;
-Balance unsteady, only able to stabilize with human assistance;
-Use of a wheelchair.
The MDS did not contain the RN signature verifying the completion date of 6/8/18.
Review of the resident’s medical record showed the staff did not complete a comprehensive
care plan by 21 days after admission or seven days after the completion date of the
admission MDS.
4. Review of Resident #31’s significant change MDS, dated [DATE], showed staff assessed
the resident as follows:
-Severe Cognitive impairment;
-Physical and verbal behavioral symptoms directed toward others 1-3 days that put the
resident at significant risk for physical illness or injury, interfere with the resident’s
care, participation in activities/social interaction, and disrupts the care environment;
-Antipsychotics were not administered during the look back period.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s Care plan, dated 4/16/18, did not contain directions for
monitoring or guidance to the staff for the resident’s antipsycotic medication.
5. Review of Resident #50’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Cognitively intact;
-Extensive physical assistance of one person for bathing;
-Minimal physical assistance of one person for bed mobility, transfers, ambulation,
dressing, toileting, and personal hygiene;
-Set up help only for eating;
-Always incontinent of bladder;
-Occasionally incontinent of bowel;
-[DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
-Scheduled pain medication for occasional pain of 3/10,
-Intentional weight loss;
-Increased risk for pressure ulcers;
-During the seven day look back period took insulin for seven days, antianxiety medication
for seven days, anticoagulant medication for seven days, antibiotic medication for five
days, and diuretic medication for seven days;
-On oxygen therapy.
Review of the POS [REDACTED].
Review of the Medication Administration Record [REDACTED]
06/18/18 – 07/17/18, showed it did not contain direction for the use of the [MEDICAL
CONDITION] or for maintenance of the [MEDICAL CONDITION] equipment.
Observation on 06/21/18 at 08:45 A.M., showed the resident in his/her room with a [MEDICAL
CONDITION] machine on the bedside table.
During an interview on 06/21/18 at 08:50 A.M., the resident said he/she uses oxygen
continuously and uses the [MEDICAL CONDITION] every night and sometimes when napping. The
resident said he/she has never seen anyone clean the [MEDICAL CONDITION] machine or change
the filters. The resident said he/she is unable to do it.
During an interview on 06/22/18 at 02:26 P.M., Licensed Practical Nurse (LPN) D said the
resident uses the [MEDICAL CONDITION] every night and, sometimes, when napping. The LPN
said he/she thinks the night shift is supposed to clean the machine. The LPN does not know
why there is not an order for [REDACTED]. The LPN said the resident is in and out of the
hospital related to his/her [MEDICAL CONDITION] and the order may not have been carried
forward. The LPN said there should be an order for [REDACTED].>6. During an interview
on 6/22/18, at 2:00 P.M., the director of nursing (DON) the comprehensive care plan is
completed and revised by the MDSC. He/She said the comprehensive care plan should be done
according to RAI manual, and should include direction to the staff to meet all the
resident’s needs, and should be updated with changes in the resident’s care.
During an interview on 6/22/18, at 4:12 P.M., the MDS coordinator (MDSC) said he/she
completes the comprehensive care plans. He/She said he/she did not complete a
comprehensive care plan for Resident #178 because they had a lot of new admissions at
once. He/She said the comprehensive care plan should be completed within 7 days of the
comprehensive assessment. He/She said the comprehensive care plan should include direction
to the staff to meet all of the resident’s needs, and should be revised and updated with
any changes to the resident’s care.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to assess,
classify, and document wounds according to National Pressure Ulcer Advisory Panel (NPUAP)
guidelines, and the Resident Assessment Instrument (RAI) manual for three resident’s
(Resident #31, and #46), and to follow pressure prevention interventions listed in the
care plan for one resident (Resident #46). The facility staff also failed to ensure the
proper functioning of a pacemaker for one resident (Resident #71) out of 18 sampled
resident’s, after the resident discontinued hospice services. The facility census was 74.
1. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated (MONTH)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
(YEAR), showed the following definitions:
-Stage 1 pressure injury is intact skin with localized area of non-blanchable (when you
press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness).
Presence of blanchable [DIAGNOSES REDACTED] changes in sensation, temperature, or firmness
may precede visual changes;
-Stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis (the
thick layer of living tissue below the top layer of skin that forms the true skin). The
wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new
connective tissue), slough (dead tissue in the process of separating from the body which
is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or
falls off from health skin) are not present;
-Stage 3 pressure injury is a full thickness loss of skin, where adipose (fat) is visible
in the ulcer and granulation tissue and rolled wound edges are often present. Slough and
eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue
damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a
thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not
exposed;
-Stage 4 pressure injury is a full-thickness skin and tissue loss with exposed or directly
palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or
eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges,
undermining and or tunneling often occur. Depth varies by location;
-Unstageable pressure injury is a full thickness skin and tissue loss in which the extent
of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or
eschar;
-Deep Tissue Pressure Injury is an intact or non-intact skin with localized area of
persistent non-intact skin with localized area of persistent non-blanchable deep red,
maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or
blood filled blister. This injury results from intense and/or prolonged pressure and shear
forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual
extent of tissue injury, or may resolve without tissue loss. If necrotic tissue,
subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures
are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or
stage 4 pressure injury).
2. Review of the Resident Assessment Instrument (RAI) manual, dated 10/1/17, directs staff
to:
-A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in combination with shear and/or
friction;
-Pressure ulcers occur when tissue is compressed between a bony prominence and an external
surface. In addition to pressure, shear force, and friction are important contributors to
pressure ulcer development;
-The underlying health of a resident’s soft tissue affects how much pressure, shear force,
or friction is needed to damage tissue. Skin and soft tissue changes associated with
aging, illness, small blood vessel disease, and malnutrition increase vulnerability to
pressure ulcers;
-Additional external factors, such as excess moisture, and tissue exposure to urine or
feces, can increase risk.
-Assess key areas for pressure ulcer development (e.g., sacrum, coccyx, trochanters,
ischial tuberosities, and heels). Also assess bony prominences (e.g., elbows and ankles)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
and skin that is under braces or subjected to pressure (e.g., ears from oxygen tubing);
-Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabetic
neuropathic ulcer. The primary etiology should be considered when coding whether a
resident with DM has an ulcer that is caused by pressure or other factors;
-If a resident with DM has a heel ulcer from pressure and the ulcer is present in the
7-day look-back period, code 1 (yes) unhealed pressure ulcers and proceed to code items
M0300-M0900 as appropriate for the pressure ulcer;
-If a resident with DM has an ulcer on the plantar (bottom) surface of the foot closer to
the metatarsals and the ulcer is present in the 7-day look-back period, code 0 (no)
unhealed pressure ulcers and proceed to M1040 to code the ulcer as a [MEDICAL CONDITION].
It is not likely that pressure is the primary cause of the resident’s ulcer when the ulcer
is in this location;
-Venous ulcers are ulcers caused by peripheral venous disease, which most commonly occur
proximal to the medial or lateral malleolus, above the inner or outer ankle, or on the
lower calf area of the leg.
-Venous ulcers may or may not be painful and are typically shallow with irregular wound
edges, a red granular (e.g., bumpy) wound bed, minimal to moderate amounts of yellow
[MEDICATION NAME] material, and moderate to large amounts of exudate. The surrounding
tissues may be [DIAGNOSES REDACTED]tous or reddened, or appear brown-tinged due to
hemosiderin staining. Leg [MEDICAL CONDITION] may also be present.
– The wound may start with some kind of minor trauma, such as hitting the leg on a
wheelchair. The wound does not typically occur over a bony prominence, and pressure forces
play virtually no role in the development of the ulcer.
-Arterial ulers are ulcers caused by [MEDICAL CONDITION], which commonly occur on the tips
and tops of the toes, tops of the foot, or distal to the medial malleolus.
– Trophic skin changes (e.g., dry skin, loss of hair growth, [MEDICAL CONDITION], brittle
nails) may also be present. The wound may start with some kind of minor trauma, such as
hitting the leg on a wheelchair. The wound does not typically occur over a bony
prominence, however, can occur on the tops of the toes. Pressure forces play virtually no
role in the development of the ulcer, however, for some residents, pressure may play a
part. Ischemia (wounds can be dark red, yellow, gray or black in color, and they usually
do not bleed) is the major etiology of these ulcers. Lower extremity and foot pulses may
be diminished or absent.
– Arterial ulcers are often painful and have a pale pink wound bed, necrotic tissue,
minimal exudate, and minimal bleeding.
-[MEDICAL CONDITION] are ulcers caused by the neuropathic and small blood vessel
complications of diabetes. [MEDICAL CONDITION] typically occur over the plantar (bottom)
surface of the foot on load bearing areas such as the ball of the foot. Ulcers are usually
deep, with necrotic tissue, moderate amounts of exudate, and callused wound edges. The
wounds are very regular in shape and the wound edges are even with a punched-out
appearance. These wounds are typically not painful.
– Diabetic [MEDICAL CONDITION] affects the lower extremities of individuals with
diabetes. Individuals with diabetic [MEDICAL CONDITION] can have decreased awareness of
pain in their feet. This means they are at high risk for foot injury. Because of decreased
circulation and sensation, the resident may not be aware of the wound.
– [MEDICAL CONDITION] can also cause changes in the structure of the bones and tissue in
the foot. This means the individual with diabetes experiences pressure on the foot in
areas not meant to bear pressure.
-Do not include pressure ulcers that occur on residents with diabetes mellitus here. For
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
example, an ulcer caused by pressure on the heel of a diabetic resident is a pressure
ulcer and not a [MEDICAL CONDITION].
-Moisture associated skin damage (MASD) is a result of skin damage caused by moisture
rather than pressure. It is caused by sustained exposure to moisture which can be caused,
for example, by incontinence, wound exudate and perspiration.
-It is characterized by inflammation of the skin, and occurs with or without skin erosion
and/or infection. MASD is also referred to as incontinence-associated [MEDICAL CONDITION]
and can cause other conditions such as intertriginous [MEDICAL CONDITION], periwound
moisture-associated [MEDICAL CONDITION], and [MEDICATION NAME] moisture-associated
[MEDICAL CONDITION]. Provision of optimal skin care and early identification and treatment
of [REDACTED].
3. Review of the facility’s Wound Care and Treatment policy, dated (MONTH) (YEAR), directs
staff how to complete a dressing change, and types of dressings for each wound type. The
facility policy does not contain directions for assessment of wounds, information to
include in the assessment, when to assess a wound, wound description, tissue type and
staging guidelines, when to report changes, or documentation requirements of any new or
existing wounds.
4. Review of Resident #31’s significant change Minimum Data Set (MDS), a federally
mandated assessment, dated 4/16/18, showed staff documented the following:
-Severe Cognitive impairment;
-One Stage 2 Pressure Ulcer developed 4/12/18, granulation tissue present;
-Dependent with the assistance of two or more staff members for bed mobility, transfers,
toilet use, personal hygiene, and bathing;
-Use of a wheelchair.
(Stage 2 pressure ulcers cannot have granulation tissue present).
Review of the resident’s admission assessment, dated 4/12/18, showed staff documented the
resident with a pressure ulcer present on the coccyx area.
Review of the resident’s Wound Report, dated 5/10/18, showed the resident with a wound to
the coccyx, unclassified, date of onset 4/12/18, acquired in the facility, deteriorated
from last assessment, measures 1 centimeter (cm) in length, 0.9 cm in width, and 0.1 cm in
depth, date of onset is 4/12/18.
Review of the resident’s Wound Report, dated 5/17/18, showed the resident with a wound to
the coccyx, unclassified, date of onset 4/12/18, acquired in the facility, deteriorated
from last assessment, measures 3 cm in length, 2.5 cm in width, and 0.1 cm in depth, date
of onset is 4/12/18.
Review of the resident’s Wound Report, dated 5/24/18, showed the resident with a wound to
the coccyx, unclassified, date of onset 4/12/18, acquired in the facility, deteriorated
from last assessment, measures 6.5 cm in length, 5 cm in width, and 0.3 cm in depth, date
of onset is 4/12/18.
Review of the resident’s Wound Report, dated 5/30/18, showed the resident with a wound to
the coccyx, unclassified, date of onset 4/12/18, acquired in the facility, healing from
last assessment, measures 6.5 cm in length, 0.5 cm in width, and 0.1 cm in depth, date of
onset is 4/12/18.
Review of the resident’s Wound Report, dated 6/5/18, showed the resident with a wound to
the coccyx, unclassified, date of onset 4/12/18, acquired in the facility, healing from
last assessment, measures 5 cm in length, 3 cm in width, and 0.2 cm in depth, date of
onset is 4/12/18.
Review of the resident’s Wound Report, dated 6/13/18, showed the resident with a wound to
the coccyx, unclassified, date of onset 4/12/18, acquired in the facility, healing from
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
last assessment, measures 6 cm in length, 0.4 cm in width, and 0.2 cm in depth, date of
onset is 4/12/18.
Observation on 6/21/18, at 11:52 A.M., showed the resident with a dressing dated 6/21/18
on his/her coccyx.
During an interview on 6/21/18, at 11:52 A.M., certified nurse assistant (CNA) C said the
resident has a small open area on his/her coccyx.
During an interview on 6/21/18, at 12:05 P.M., licensed practical nurse (LPN) D said the
resident has an open area on the coccyx. He/She said the wound is on the inner buttocks in
the coccyx area.
Observation on 6/21/18, at 3:49 P.M., showed the resident with a showed dime sized open
area longer than wide on his/her coccyx, along the sacral bony prominence. Observation
showed the wound bed with yellow slough, thin line of granulation tissue around the edges
of the wound bed, and a dark black eschar area in the center. Observation showed the
periwound had purple nonblanchable tissue around the wound.
During an interview on 6/21/18, at 3:49 P.M., RN E said he/she classified the area as
moisture associated [MEDICAL CONDITION]. He/She said the wound measures 1.4 cm in length,
0.8 cm in width, and 0.3 cm in depth. He/She said the wound had 3%eschar, 80% slough, and
27 % granulation tissue, and the periwound purple area is nonblanchable.
During an interview on 6/21/18, at 3:55 P.M., LPN D said the open area is a pressure ulcer
from the hospital, and it is documented on the admission assessment. He/She said he/she is
not sure if the wound is on the care plan, but with the tissue present, the wound is at
least a Stage 3 pressure ulcer.
5. Review of Resident #46’s quarterly MDS, dated [DATE], showed staff documented the
resident as follows:
-Severe cognitive impairment;
-Limited assistance of one staff member for transfers;
-Extensive assistance of one staff member with bed mobility, locomotion, dressing, toilet
use, hygiene, and bathing;
-Always incontinent of bladder, and occasionally incontinent of bowels;
-Resident denies pain in the last 5 days;
-At risk of developing pressure ulcers;
-One venous/arterial ulcer;
-Pressure reduction device to chair;
-No pressure reduction device to bed;
-Application of nonsurgical dressings other than to feet;
-Application of ointments/medications other than to feet.
Review of the resident’s physician’s orders [REDACTED].
-Right heel clean with normal saline, apply skin prep to blister;
-Left heel clean with normal saline, apply skin prep to heel.
Review of the resident’s care plan, dated 2/1/18, directed staff to:
-prevent injury/trauma to feet;
-Use pressure relief devices to bilateral lower extremities;
-Avoid pressure and sheering to lower extremities.
Review of the resident’s Initial and Weekly Wound Documentation, dated 6/10/18, showed the
staff documented:
-New wound to the left heel;
-Blister;
-6 cm in length, 5 cm in width, fluid filled blister with some blood under blister;
-Date of onset 6/9/18;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
-Heel protectors.
Review of the resident’s Initial and Weekly Wound Documentation, dated 6/14/18, showed the
staff documented:
-New wound to the right heel;
-40%eschar and 60% epithelium present;
-1.5 cm in length, 3 cm in width, depth undeterminable;
-Date of onset 6/10/18;
-Heel protectors.
During an interview on 6/19/18, at 12:41 P.M., the resident’s spouse said the resident has
blisters on his/her heels. He/She said he/she believes the blisters are from staff
dragging the resident around to do activities the resident doesn’t want to do. He/She said
he/she doesn’t know why else the resident would have blisters on his/her heels. The spouse
said the resident does not move unless he/she is here, and many times the resident does
not have dressings on his/her wounds.
Observation on 6/20/18, at 11:50 A.M., showed the resident in the dining room with socks
on his/her feet. Observation showed he/she did not have heel protectors on. His/her feet
rested on the tile floor.
Observation on 6/21/18, at 10:12 A.M., showed the resident with a vascular wound on
his/her shin. The ulceration presented approximately half dollar size in an oval shape
with smooth rolled edges with 10% red granulation, 90 % slough and white maceration.
Further observation showed the resident’s wound to his/her right outer heel, long with
irregular edges, deep purple appearance of blood filled blister, nonblanchable, his/her
outer skin showed to be intact. Observation of the resident’s left inner heel showed a
large, irregular shaped, blood filled blister.
During an interview on 6/21/18, at 10:15 A.M., the registered nurse (RN) E said the
resident’s right outer heel measures 2.2 cm in length, and 1.7 cm in width and appears as
a blood filled blister but is not raised. He/She said the raised blood filled blister on
the resident’s left inner heel measures 4.3 cm in length, and 4.4 cm in width. The RN said
that he/she would classify the heel wounds as Stage 2 pressure ulcers, the right heel may
be an unstageable or deep tissue injury. He/She said he/she did not see the wounds right
after they were found but felt they were caused by pressure. He/She said the staff are
expected to float the resident’s heels when he/she is in bed, and the resident is to have
heel protectors on when he/she is out of bed.
During an interview on 6/21/18, at 1:30 P.M., the nurse practitioner from the wound clinic
said he/she classified the heel wounds as arterial because the wounds are not directly on
the back of the resident’s heels and the resident is diabetic with bad circulation.
6. During an interview on 6/22/18, at 4:12 P.M., the MDS coordinator (MDSC) said he/she
does not know the RAI manual guidance on granulation tissue or pressure compared to
arterial wounds. He/she said he/she has to go off of what the wound nurse documents.
He/She said all staff that complete the MDS are expected to complete the MDS according to
the RAI manual.
During an interview on 6/22/18, 4:12 P.M., the director of nursing (DON) said he/she did
not know Resident #31 has an open wound. He/She said wounds should be staged according to
the RAI manual, and the NPUAP guidelines.
7. Review Resident #71’s documentation from the hospital showed the following:
-Date of service 11/1/17;
-Reason for consultation: evaluation of the patient for a possible implantable
cardioverter-defibrillator (ICD) discharge;
-Recommendation: consideration for discontinuing defibrillator therapy should be raised
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
with the family.
Review of the resident’s medical record showed the following:
-[DIAGNOSES REDACTED].
-Code status of Do Not Resuscitate (DNR);
-Hospice order date of 11/15/17, admitted on [DATE], and discontinued on 5/13/18;
-physician progress notes [REDACTED].
-No care instructions for the automatic (implantable) cardiac defibrillator on the
physician orders;
– Automatic (implantable) cardiac defibrillator not addressed in the care plan;
-No documentation of discussion with family regarding discontinuing defibrillator therapy;
-No documentation of a follow-up appointment with cardiologist.
During an interview on 6/22/18, at 5:30 P.M., the director of nursing (DON) said the
resident did not have his/her pacer checked. He/She said the resident came off hospice
services a month ago, and it should have been scheduled, but it was overlooked. He/She
said the resident is not scheduled at this time to get checked. The DON said the resident
went to the VA to have it checked in the past.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to bathe four
resident’s (Resident #31, #57, #70, and #178) to meet their hygiene needs. The facility
census was 74.
1. Review of Resident #31’s significant change Minimum Data Set (MDS), a federally
mandated assessment tool, dated 4/16/18, showed staff assessed the resident as follows:
-Severe Cognitive impairment;
-Dependent with the assistance of two or more staff members for bed mobility, transfers,
toilet use, personal hygiene, and bathing;
-Always incontinent of bowel and bladder;
-Use of a wheelchair.
Review of the resident’s care plan, dated 4/16/18, showed staff are directed as follows:
-Extensive to dependent assist of 1-2 staff members for bed mobility, transfers,
locomotion, dressing, toileting, personal hygiene, and bathing;
-Incontinent of bowel and bladder;
-Use of mechanical lift for all transfers.
Review of the resident’s shower sheets, dated 5/1/18-5/31/18, showed staff documented the
resident received five out of nine scheduled baths. Additional review showed the resident
went nine days without a bath documented from 5/10-5/18/18. The documentation did not
contain resident refusal of showers.
Review of the resident’s shower sheets, dated 6/1/18-6/22/18, showed staff documented the
resident received four out of six scheduled baths. Further review showed the resident went
nine days without a bath documented from 5/31-6/8/18. The documentation did not contain
resident refusal of showers.
Observation on 6/21/18, at 8:50 A.M., showed the resident’s hair greasy.
2. Review of Resident #57’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-Moderate cognitive impairment;
-Limited physical assistance of one staff member for bed mobility, transfers, dressing,
hygiene, and bathing;
-Occasionally incontinent of bowel and bladder;
-Balance not steady;
-Use of a walker or wheelchair.
Review of the resident’s care plan, dated 12/11/17, shows staff assessed the resident
required the assistance of one staff to bathe.
Review of the resident’s shower sheets, dated 5/1/18-5/31/18, showed staff documented the
resident received three out of nine scheduled baths. Further review showed the resident
went twenty days without a bath documented from 5/1-5/20/18. Additional review showed
staff documented the resident refused one bath during this time.
Review of the resident’s shower Sheets, dated 6/1/18-6/22/18, showed staff documented the
resident received three out of six scheduled baths. Further review showed the resident
went seven days without a bath documented from 6/15-6/20/18, and staff documented the
resident refused one bath offered on 6/7/18.
Observation on 6/20/18, at 3:43 P.M., showed the resident’s hair is greasy.
During an interview on 6/20/18, at 3:43 P.M., the resident said he/she does not get
showers when he/she wants them. He/She said if the staff offer a shower and he/she cannot
do a shower at that time, the staff does not offer another time. He/She said the staff do
not offer him/her at least two showers a week. He/She said he/she always hopes that no one
notices he/she missed a bath and tries to make sure he/she does not have an odor.
3. Review of Resident #70’s annual MDS, dated [DATE], showed staff documented the resident
as follows:
-Severe cognitive impairment;
-Rarely or never understood;
-Sometimes understands, responds adequately to simple, direct communication only;
-Extensive physical assistance of one staff member for locomotion;
-Extensive physical assistance of two staff members for bed mobility, transfers, dressing,
toilet use, and hygiene;
-Always incontinent of bowel and bladder.
Review of the resident’s care plan, dated 11/22/17, showed staff assessed the resident
resident is incontinent of bowel and bladder, and is dependent on one to two staff with
bathing.
Review of the resident’s shower sheets, dated 5/1/18-5/31/18, showed staff documented the
resident received seven out of nine scheduled baths. Further review showed the resident
went seven days without a bath documented. The documentation did not contain documentation
of the resident refusal of showers.
Review of the resident’s shower sheets, dated 6/1/18-6/22/18, showed staff documented the
resident received three out of six scheduled baths. Further review showed the resident
went nine days without a bath documented from 5/31-6/8/18. The documentation did not
contain documentation of the resident refusal of showers.
Observation on 6/20/18, at 3:16 P.M., showed the resident’s hair greasy and his/her facial
hair unkempt.
4. Review of Resident #178’s admission MDS, dated [DATE], showed staff documented:
-Admission to the facility on [DATE];
-Severe cognitive impairment;
-Sometimes understood/understands;
-Always incontinent of bowel and bladder;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
-Limited physical assistance of one staff member for ambulation, locomotion, and eating;
-Extensive assistance of two staff members for bed mobility, transfers, dressing, toilet
use, and bathing;
-Balance unsteady, only able to stabilize with human assistance;
-Use of a wheelchair.
Review of the resident’s baseline care plan, dated 6/19/18, showed staff assessed the
resident required two staff members to bathe.
Review of the resident’s shower sheets, dated 6/1/18-6/22/18, showed staff documented the
resident received three out of six scheduled baths. The documentation did not contain
documentation of the resident refusal of showers.
Observation on 6/20/18, at 10:06 A.M., showed the resident with long unkempt facial hair,
his/her fingernails long with brown substance under them, and long toenails.
5. During an interview on 6/22/18, at 4:12 P.M., the MDS coordinator (MDSC) said the
resident’s showers should be done twice a week on Mondays and Thursdays or Wednesdays and
Saturdays. He/She said if the resident does not want a shower/bath, staff offer a bed
bath. He/She said the facility schedules bath aides, but if the bath aide has to take an
assignment on the floor, then the aide responsible for that hall is responsible for the
baths. He/She said staff are expected to document when a resident receives a shower on the
shower sheets, and document refusals or the reason a shower does not get done. He/She said
if staff do not have time to complete a shower, they are expected to pass it on to the
next shift.
During an interview on 6/22/18, at 4:14 P.M., certified nurse assistant (CNA) B said if
baths are not completed on the day shift, staff are expected to pass the responsibility to
the next shift. He/She said staff are expected to document every shower/bath on a shower
sheet, and if the resident refuses, staff document the refusal and why on the shower
sheet. He/She said resident’s should be bathed at least twice a week. He/She said he/she
does not know why the baths did not get done. The CNA said either the staff did not
document them or they were missed.
During an interview on 6/22/18, at 2:00 P.M., the director of nursing (DON) said staff are
expected to bathe resident’s twice a week and the CNA’s are expected to document on the
shower sheets. He/She said the CNA’s should document on the shower sheet if they offer a
shower and the resident declines. The DON said if staff are unable to complete their
showers, staff are expected to pass the task to the next shift to complete.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, resident and staff interview and record review, facility staff
failed to provide an ongoing program of activities designed to meet the resident’s
interests for three sampled residents (Residents #31, #70, #178), and failed to provide
weekend and evening activities for all resident’s. The facility census was 74.
1. Review of the facility’s Activity Calendar, dated (MONTH) (YEAR), listed the following
activities scheduled:
-June 1st: 9:30 A.M. Exercise and Games, 10:00 A.M. Rolling for prizes, 1:00 P.M. Nails,
2:30 Bingo;
-June 2nd: 10:00 A.M. Bingo, Go outside, Play a board game;
-June 3rd: 9:00 A.M. Baptist church, 1:00 P.M. Church of Christ, 3:00 P.M. Baptist church;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-June 4th: 9:30 A.M. Exercise and Games; 10:00 A.M. What’s cooking; 1:00 P.M. Sing a long;
2:30 P.M. Bingo;
-June 5th: 8:00 A.M. Clip N Curl , 10:00 A.M. Movie Time, 1:00 P.M. Trivia, 2:30 P.M. Ice
cream parlor;
-June 6th: 9:30 A.M. Exercise and Games, 10:00 A.M. Crafts, 1:00 P.M. Music, 2:30 P.M.
Bingo;
-June 7th: 10:00 A.M. Baptist church, 1:00 P.M. Calmar, 2:30 P.M. Nachos;
-June 8th: 9:30 A.M. Exercise and Games, 10:00 A.M. Lets make a deal, 1:00 P.M. Nails,
2:30 P.M. Bingo;
-June 9th: 10:00 A.M. Bingo, Watch a movie on channel 18, Puzzle time;
-June 10 th: 9:00 A.M. Baptist Church, 3:00 P.M. Evangelical Holiness;
-June 11 th; 9:30 A.M. Exercise and Games, 10:00 A.M. What’s cooking, 1:00 P.M. Pet
therapy, 2:30 P.M. Bingo;
-June 12 th: 8:00 A.M. Clip N Curl, 10:00 A.M. Movie and snacks, 2:30 P.M. Ice cream
parlor;
-June 13 th: 9:30 A.M. Exercise and Games, 10:00 A.M. Trivia, 1:00 P.M. Music, 2:30 P.M.
Bingo;
-June 14 th: 10:00 A.M. Baptist church, 1:00 P.M. WalMart, 2:30 P.M. Ice cream parlor;
-June 15 th; 9:30 A.M. Exercise and Games, 10:00 A.M. Rolling for prizes, 10:30 Fathers
day celebration, 1:00 P.M. Nails, 2:30 Bingo;
-June 16 th: 10:00 A.M. Bingo, Watch a movie on channel 18, Puzzle time;
-June 17 th: 9:00 A.M. Baptist church;
-June 18 th: 9:30 A.M. Exercise and Games, 10:00 A.M. What’s cooking, 1:00 P.M. Pet
therapy, 2:30 P.M. Bingo;
-June 19 th: 8:00 A.M. Clip N Curl , 10:00 A.M. Movie and snacks, 2:30 P.M. Ice cream
parlor, 6:30 P.M. Bingo;
-June 20 th: 9:30 A.M. Exercise and Games, 10:00 A.M. Church, 1:00 P.M. Music, 2:30 P.M.
Bingo;
-June 21st: 10:00 A.M.Baptist church, 1:00 P.M. WalMart, 2:30 P.M. Nachos;
-June 22nd: 9:30 A.M. Exercise and Games, 10:00 A.M. Lets make a deal, 1:00 P.M. Nails,
2:30 P.M. Bingo;
-June 23rd: 10:00 A.M. Bingo, Play a board game, Watch a ball game;
-June 24th: 9:00 A.M. Baptist church, 1:00 Apostolic church;
-June 25th: 9:30 A.M. Exercise and Games, 10:00 A.M. What’s cooking, 1:00 P.M. Pet
therapy, 2:30 P.M. Bingo;
-June 26th: 8:00 A.M. Clip N Curl , 10:00 A.M. Movie and snacks, 2:30 P.M. Ice cream
parlor;
-June 27th: -June 20th: 9:30 A.M. Exercise and Games, 10:00 A.M. Resident Council, 1:00
P.M. Music, 2:30 P.M. Bingo;
-June 28th: 9:00 A.M. Baptist church, 1:30 P.M. Birthday party;
-June 29th: 9:30 A.M. Exercise and Games, 10:00 A.M. Rolling for prizes, 1:00 P.M. Nails,
2:30 Bingo;
-June 30th: 10:00 A.M. Bingo, Play cards, Read, Watch a ball game.
2. Review of Resident #31’s significant change Minimum Data Set (MDS), a federally
mandated assessment tool, dated 4/16/18, showed staff assessed the resident as follows:
-Severe Cognitive impairment;
-Enjoys listening to music, doing things with groups of people, and participating in
favorite activities;
-Dependent with the assistance of two or more staff members for bed mobility, transfers,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
toilet use, personal hygiene, and bathing;
-Use of a wheelchair.
Review of the resident’s care plan, dated 4/16/18, showed staff are directed to:
-Inform the resident of upcoming activities by providing activity calendar, verbal
reminders, escort and encouragement;
-Provide one on one activities as needed;
-Resident will occasionally watch TV in his/her room or in the day room;
-The resident will look out the window.
Review of the resident’s activities assessment, dated 5/28/18, showed staff assessed the
resident as follows:
-Awake all or most of the morning and afternoon;
-Common use of the resident’s time is watching TV, looking outside, and listening to
music;
-Preferred program style one on one, small groups, independent leisure;
-Activity preferences of spiritual/religious activities, music, watching TV, and talking
or conversing;
-Focus of programming: one on one, relaxation, intellectually stimulating, religious, and
talk-oriented activities.
Review of the resident’s Daily activity Participation Log, dated 6/1/18-6/21/18, showed
staff documented the resident attended the following:
-Church on one day;
-Ice cream on three days;
-Nachos on one day;
-One one on one 8 days;
-Pet therapy, TV, Radio, and looking outside checked everyday.
Further review showed the resident did not attend the three music activities, only
attended one group event, and a television schedule or preference of programming is not
available for the staff to meet the resident’s interest.
Observation on 6/19/18, at 12:41 P.M., showed the resident in his/her recliner on wheels,
in front of the window at the end of the hall outside of his/her room. Observation showed
the resident’s chair in the furthest relined position and his/her eyes closed.
Observation on 6/20/18 at 9:51 A.M., showed the resident in front of his/her television
turned to a western program. The resident yelled help, he wont eat repeatedly.
Observation on 6/20/18, at 1:10 P.M., showed the resident in his/her bed. Further
observation showed a live music activity in the facility and the resident did not attend.
Observation on 6/21/18 at 9:22 A.M., showed the resident in his/her recliner on wheels, in
front of the window at the end of the hall outside of his/her room. Observation showed the
resident’s chair in the furthest relined position and his/her eyes closed.
3. Review of Resident #70’s annual MDS, dated [DATE], showed staff assessed the resident
as follows:
-Severe cognitive impairment;
-Rarely or never understood;
-Sometimes understands, responds adequately to simple, direct communication only;
-Somewhat important to choose what clothes to wear, take care of personal belongings,
choose type of bath, choose bedtime, have family or a close friend involved in discussions
about your care, listen to music, be around animals, go outside when the weather is good;
-Extensive physical assistance of one staff member for locomotion;
-Extensive physical assistance of two staff members for bed mobility, transfers, dressing,
toilet use, and hygiene.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
Review of the resident’s care plan, dated 11/22/17,shows staff are directed to:
-Inform the resident of upcoming activities by providing activity calendar, verbal
reminders, escort and encouragement;
-Provide one on one activities at least three times a week;
-Resident will watch TV in his/her room or in the day room, he/she likes hunting, animal
planet, or animal shows;
-The resident will look out the window.
Review of the resident’s activities assessment, dated 6/5/18, showed staff documented the
following:
-Awake all or most of the morning and afternoon;
-Interest of the resident’s is watching TV, listening to music, religious, and going
outdoors;
-Preferred program style one on one, small groups, independent leisure;
-Activity preferences of spiritual/religious activities, music, watching TV, and talking
or conversing;
-Focus of programming: one on one, relaxation, outdoor, religious, social, independent,
and talk-oriented activities.
Review of the resident’s Daily activity Participation Log, dated 6/1/18-6/21/18, the staff
documented the resident attended the following:
-Barber shop on one day;
-Church-the resident attended one out of 10 religious activities;
-Exercise on one day;
-Music and Memory on seven days;
-One on one on seven days;
-Pet therapy, TV, Radio, and looking outside checked everyday.
Further review showed the resident did not attend the three music activities or go
outdoors, and only attended one group event.
Observation on 6/20/18 at 9:49 A.M., showed the resident in his/her bed. Observation
showed his/her television with cartoons on.
Observation on 6/20/18, at 1:10 P.M., showed the resident in his/her bed. Further
observation showed a live music activity in the facility and the resident did not attend.
Observation on 6/21/18 at 9:23 A.M., showed the resident in his/her bed. Observation
showed his/her television with cartoons on.
4. Review of Resident #178’s admission MDS, dated [DATE], showed staff documented the
following:
-Admission to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Severe cognitive impairment;
-Sometimes understood/understands;
-Enjoys listening to music, being around animals, doing things with groups of people, and
participating in favorite activities;
-Limited physical assistance of one staff member for ambulation, locomotion, and eating;
-Extensive assistance of two staff members for bed mobility, transfers, dressing, toilet
use, and bathing;
-Use of a wheelchair.
Review of the resident’s activities assessment, dated 6/12/18, showed staff documented the
following:
-Awake all or most of the morning and afternoon;
-Common use of the resident’s time is watching TV, napping, or one on one activities;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
-Spends less than 1/3 of his/her time in activities;
-Activity preferences of exercise/sports, music, watching TV, and talking or conversing;
-Past interest include animals/pets, board games, cooking, current events, dining out,
movies, painting, and woodworking;
-Focus of programming: one on one, sensory stimulation, reality orientation, and
validation activities.
Review of the resident’s baseline care plan, dated 6/19/18, did not contain direction to
the staff on the resident’s activity needs.
Review of the resident’s medical record did not contain the resident’s comprehensive care
plan.
Review of the resident’s Daily activity Participation Log, dated 6/1/18-6/21/18, staff
documented the resident attended the following:
-Ice cream on four days;
-Nachos on one day;
-One on one on eight days (details of the activities provided are not documented);
-Pet therapy, TV, and Radio checked everyday.
Further review showed the resident did not attend the three music activities, only
attended one group event, and a television schedule or preference of programming is not
available for the staff to meet the resident’s interest.
5. During a group interview, on 6/20/18 at 9:00 A.M., with 10 residents identified by the
facility as alert and oriented, the residents said there are activities on the weekend. On
Saturday morning there is bingo, and on Sunday there is church. There are no other
activities on the weekend.
6. During an interview on 6/21/18, at 11:52 A.M., certified nurse assistant (CNA) C said
he/she sees the activity staff bring ice cream to some resident’s that stay in their
rooms. He/She does not see them do one on one with the resident’s. He/She said the dogs
belong to activity staff and they follow him/her around but he/she does not see them spend
time in individual resident’s rooms. He/She said there is not a list of who the staff
should bring to church or music activities. The CNA also said there is bingo on Saturdays
and church on Sundays but not much else going on the weekends. He/She does not know what
the resident’s who cannot play bingo or like church, do for entertainment on the weekend.
7. During an interview on 6/22/18 at 3:10 P.M., the Activity Director (AD) said he/she is
the only staff in the activity department and his/her hours are from 8/8:30 A.M. to
4:30/5:00 P.M., Monday through Friday. He/She lost all his/her activity aides due to
Medicaid cuts. He/She keeps track of each resident’s participation in the activity
notebook. The AD said he/she puts a calendar in each residents’ room, announces the
activities daily on the overhead speakers, and he/she goes up and down the halls to invite
each resident to the activity. He/She marks watching television and listening to the radio
activities every day for each resident. The majority of residents enjoy both activities,
so he/she automatically marks them for each day of the month. He/She does not see them
actually watching television or listening to the radio. He/She marks them so the aides
know the resident enjoys that activity. The AD said it is possible the resident has not
done either activity even though he/she has marked it in the activity book. He/She knows
which residents get visitors and which have family or friends visit every day, and some
residents have visitors once a week. Sometimes he/she will see the resident with a visitor
when he/she walks up and down the hall or he/she will pass a visitor in the hallway. Other
times, when he/she talks to the resident, he/she will ask them if anyone has visited them.
If the resident says yes then he/she will mark it in the activity book. He/she may not
actually see the resident with the visitor even though he/she has marked it in the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
activity book. His/She said his/her definition of activity is when the residents do
something with him/her. He/she would not consider watching television, listening to the
radio, or having a visitor as an activity because the resident is not doing it with
him/her. A resident’s care plan outlines which activities the resident enjoys. Care plan
meetings occur quarterly, and he/she attends the meetings. The care plan is the only place
to record a resident is not participating in activities. It would be beneficial to record
whether a resident comes to or participates in activities. A resident who does not
regularly attend may need one-to-one activities. A resident who consistently declines
one-to-one activities may need a different approach. Residents who cannot speak or
communicate let him/her know which activities he/she enjoys by nodding or shaking his/her
head to specific questions. There is one evening activity a month, typically a music
group. Most residents go to bed early so there is no need for evening activities. If a
resident stays up later than that, they can do puzzles or watch television or movies.
There are activities on both Saturday and Sunday. On Saturday, bingo is from 10:00-11:00
A.M. After 11:00 A.M., there are no activities. On Sundays, there is church throughout the
day. There are no other activities besides church. If a resident does not attend church
then there are no organized activities for them to do on Sundays.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to ensure
cleaning and disinfecting of a Continuous Positive Airway Pressure ([MEDICAL CONDITION])
machine (including cleaning of the mask, tubing and humidifier tub), used to treat
obstructive sleep apnea, for one resident (Resident #50), to prevent the growth of
bacteria, viruses, mold, and fungi. The facility census was 74.
1. Review of the facility’s policy titled Continuous Presssure Airway Pressure ([MEDICAL
CONDITION]) Administration, dated (MONTH) (YEAR), shows the purpose is to provide
continuous positive airway pressure to maintain open airway to the resident with
obstructive sleep apnea or respiratory problems breathing when sleeping.
Staff are directed to check the physician’s orders [REDACTED].
General Guidelines for Care and Cleaning of the [MEDICAL CONDITION] device, including
masks, head gear, tubing, and the humidifier, shows staff are directed to:
-Use a wet cloth or cleaning wipe to clean the outside surface of the [MEDICAL CONDITION]
machine;
-Reusable filter:
1. Remove the back filter from the [MEDICAL CONDITION] machine;
2. Clean the back filter weekly by running it under warm tap water, squeezing the
water out of it until it runs clear of dust;
3. Blot the filter dry with a clean dry cloth, replace it in the machine;
4. Replace this filter with a new one once a year;
5. Disposable filters are to be replaced monthly or whenever torn or discolored. The
white disposable filters may not be washed;
-For safety, unplug the unit when cleaning. Begin with wiping the outside of the [MEDICAL
CONDITION] unit with a damp cloth and let air dry;
-Inspect the filters on the unit. One filter is usually a foam material that is easily
taken out from the device by pinching the middle of the foam. The filter is normally found

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
in the rear of the unit, but check the manual if it is not found. This filter should be
cleaned with water and mild soap once every two weeks of use. The inner filter that is
ultra fine should be replaced every 30 days of use. If it appears dirty before 30 days,
replace it. Do not clean the white filter;
-The tubing should be cleaned weekly. Particles from the air can gather in the tubing
through use, and mold can even accumulate, which is dangerous to inhale. Remove the tubing
from the devise and rinse with water and mild soap, swishing the water back and forth
through the tube and emptying. Rinse thoroughly and air dry;
-The mask and nasal pillows connection can be wiped daily with a damp cloth and mild soap.
Rinse and allow to air dry;
-The mask and nasal pillows connection can be wiped daily with a damp cloth and mild soap.
Rinse and allow to air dry;
-If the unit has a humidifier, check to make sure there is enough distilled/tap water in
the unit. Clean the holding tank with a damp cloth and mild soap weekly. For disinfecting
the holding tank, use vinegar and water, mix, and let sit in the holder for approximately
30 minutes. Rinse thoroughly and air dry.
2. Review of Resident #50’s quarterly Minimum Data Set ((MDS) dated [DATE], showed staff
assessed the resident:
-Cognitively intact;
-Extensive physical assistance of one person for bathing;
-Minimal physical assistance of one person for bed mobility, transfers, ambulation,
dressing, toileting, and personal hygiene;
-Set up help only for eating;
-Always incontinent of bladder;
-Occasionally incontinent of bowel;
-[DIAGNOSES REDACTED].
-Scheduled pain medication for occasional pain of 3/10,
-Intentional weight loss;
-Increased risk for pressure ulcers;
-During the seven day look back period took insulin for seven days, antianxiety medication
for seven days, anticoagulant medication for seven days, antibiotic medication for five
days, and diuretic medication for seven days;
-On oxygen therapy.
Additional review showed the MDS did not address the [MEDICAL CONDITION] use.
Review of the resident’s care plan dated 03/18/18, showed it did not contain direction for
use or maintenance of the [MEDICAL CONDITION].
3. Review of the Physician order [REDACTED].
4. Review of the Treatment Administration Record (TAR) dated 06/18/18-7/17/18, showed it
did not contain direction for staff regarding use and maintenance of the [MEDICAL
CONDITION] machine.
5. Observation on 06/21/18 at 08:45 A.M., showed the resident’s [MEDICAL CONDITION] mask
on the top of the [MEDICAL CONDITION] machine.
6. During an interview on 06/22/18 at 9:20 A.M., the resident said he/she uses the
[MEDICAL CONDITION] to sleep at night or when napping. The resident said he/she has never
seen staff provide cleaning or maintenance for the [MEDICAL CONDITION] machine. The
resident said he/she is concerned the machine is not cleaned properly.
7. During an interview on 06/22/18 at 02:26 P.M., LPN D said the resident has a [MEDICAL
CONDITION] in his/her room and uses it every night and also when napping. The LPN said the
night shift is supposed to clean the [MEDICAL CONDITION] machine. The LPN said there
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
should be an order for [REDACTED]. The LPN said the resident has occasionally been in the
hospital and the order may not have been carried over when the resident returned.
8. During an interview on 06/22/18 at 4:12 P.M., the MDS Coordinator (MDSC) said oxygen
tubing should be changed once a week on Fridays. He/She said [MEDICAL CONDITION] masks do
not have a cleaning schdule he/she knows of, and he/she does not know how to clean them.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to obtain stop
dates of 14 days or less for PRN (as needed) medications for six residents (Resident #10,
#17, #31, #32, #46, and #178) out of 18 sampled residents. The facility census was 74.
1. Review of the facility policy Antipsychotic Medication Use, dated (MONTH) (YEAR),
directs staff to:
-Antipsychotic medication therapy shall be used only when it is necessary to treat a
specific condition for which they are indicated and effective;
-The attending physician and facility staff will identify acute psychiatric episodes, and
will differentiate them from enduring psychiatric conditions;
-The physician will identify, evaluate and document symptoms that may warrant the use of
antipsychotic medications;
-Based on assessing the resident’s symptoms and overall situation, the physician will
determine whether to continue, adjust, or stop existing antipsychotic medication;
-If antipsychotic medication are administered as PRN dosages repeated over several days,
the physician should discuss the situation with staff and evaluate the resident as needed
to determine whether the use is appropriate and the symptoms are responding to the
medication.
2. Review of Resident #10’s significant change MDS, dated [DATE], showed staff assessed
the resident as follows:
-Cognitively impaired;
-[DIAGNOSES REDACTED].
-During the seven day look back period, took antipsychotic medication five days and
antianxiety medication one day.
Review of the resident’s Physician’s Order Sheet (POS), dated 06/18/18-07/17/18, showed
staff are directed to administer [MEDICATION NAME] oral concentrate (2 mg / ml) 0.125 ml
(0.25 mg) by mouth every 4 hours as needed for anxiety. The physician’s order did not
contain a stop date.
3. Review of Resident #17’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively intact;
-[DIAGNOSES REDACTED].
-Administered antianxiety, and antidepressant medication daily.
Review of the resident’s Physician’s Order Sheet (POS), dated 6/18/18-67/17/18, showed
staff are directed to administer [MEDICATION NAME] (medication for anxiety 0.25 mg twice a
day PRN. The physician’s order did not contain a stop date.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
Further review of the resident’s medical record, shows it did not contain a medical
indication for a PRN antipsychotic without a stop date of 14 days or less.
4. Review of Resident #31’s significant change MDS, dated [DATE], showed staff assessed
the resident as follows:
-Severe Cognitive impairment;
-Physical and verbal behavioral symptoms directed toward others 1-3 days that put the
resident at significant risk for physical illness or injury, interfere with the resident’s
care, participation in activities/social interaction, and disrupts the care environment;
-Antipsychotics were not administered during the look back period.
Review of the resident’s POS, dated 6/18/18-67/17/18, showed staff are directed to
administer [MEDICATION NAME] (medication for anxiety 0.25 mg three times a day PRN for
anxiety. The physician’s order did not contain a stop date.
Further review of the resident’s medical record, shows it did not contain a medical
indication for a PRN antipsychotic without a stop date of 14 days or less.
5. Review of Resident #32’s significant change MDS, dated [DATE], showed staff assessed
the resident as follows:
-Cognitively impaired;
-[DIAGNOSES REDACTED].
-During the seven day look back period took seven days of antianxiety medication and seven
days of an antidepressant medication.
Review of the resident’s POS, dated 06/18/18 – 07/17/18, showed an order dated, 11/15/17,
(a duplicate 6/7/18 was discontinued) for [MEDICATION NAME] 0.5 mg one tablet every 6
hours as needed for anxiety. The order had a stop date 8/19/18 which is not within the two
week guidelines for a stop date.
6. Review of Resident #46’s quarterly MDS, dated [DATE], shows staff documented the
following:
-Severely impaired cognitive skills;
-[DIAGNOSES REDACTED].
-Administered antianxiety and antidepressant medication daily.
Review of the resident’s POS, dated 6/18/18 – 7/17/18, showed the following:
-An order dated 8/24/16 for [MEDICATION NAME] (medication for anxiety) 0.5 mg, three times
a day, PRN;
-A stop date of 8/19/18.
Review of the resident’s medical record showed it did not give a medical indication for a
PRN antipsychotic without a stop date of 14 days or less.
7. Review of Resident #178’s admission MDS, dated [DATE], showed staff documented the
following:
-Admission to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Severe cognitive impairment;
-Sometimes understood/understands;
-Verbal behaviors and other behavioral symptoms not directed at others 1-3 days;
-Behaviors significantly interfere with the resident’s care, and with the resident’s
participation in activities or social interaction;
-Behaviors significantly intrude on the privacy or activity of others, and disrupt
care/living environment;
-Rejection of care 1-3 days;
-Signs of possible pain present in the last 5 days: non-verbal sounds, vocal complaints,
and facial expressions;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265652

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

06/22/2018

NAME OF PROVIDER OF SUPPLIER

CUBA MANOR INC

STREET ADDRESS, CITY, STATE, ZIP

210 ELDON DRIVE
CUBA, MO 65453

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-Fall prior to admission, one fall without injury since admission, and one fall with
injury since admission;
-Antianxiety and opioid medication every day.
Review of the resident’s POS, dated 6/18/18-67/17/18, showed staff are directed to
administer:
-[MEDICATION NAME] (medication for anxiety) 0.5 mg every 2 hours PRN for shortness of
breath and pain
-[MEDICATION NAME] (medication for hallucinations and delusions) 2 mg/ml every 4 hours for
agitation or nausea may titrate to 5 mg PO every four house if ineffective for symptom
control
-[MEDICATION NAME] HCL (medication used for itching, allergies [REDACTED].
The physician’s orders did not contain a stop date.
Further review of the resident’s medical record, shows it did not contain a medical
indication for a PRN antipsychotic without a stop date of 14 days or less.
8. During an interview on 6/22/18, at 9:14 A.M., licensed practical nurse (LPN) A said PRN
[MEDICAL CONDITION] should have a stop date of 14 days or less. He/She said he/she is not
sure who checks it.
During an interview on 6/22/18, at 2:00 P.M., the director of nursing (DON) said [MEDICAL
CONDITION] PRN’s should have a stop date of 14 days or less, and the pharmacist has been
working on them. He/She said he/she did not know there were that many left without a stop
date.
During an interview on 6/22/18, at 4:12 P.M., MDS coordinator (MDSC) said PRN [MEDICAL
CONDITION] are to have a stop date within 14 days unless a doctor says otherwise. He/She
said he/she has not seen anyone document why to extend the stop date so he/she is not sure
what they are supposed to document.