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Deficiency Records for Havana Health Care Center

A list of the most recent deficiencies for Havana Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Havana Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-06-20 2024-08-30 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2024-06-07 2024-08-09 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-06-07 2024-08-09 N
Respond appropriately to all alleged violations. Health 2024-06-07 2024-08-09 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2024-06-07 2024-08-09 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2024-06-07 2024-08-09 N
Ensure the activities program is directed by a qualified professional. Health 2024-06-07 2024-08-09 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2024-06-07 2024-08-09 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2024-06-07 2024-08-09 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2024-06-07 2024-08-09 N
Provide and implement an infection prevention and control program. Health 2024-06-07 2024-08-09 N
Keep all essential equipment working safely. Health 2024-06-07 2024-08-09 N
Provide activities to meet all resident's needs. Health 2024-06-07 2024-08-09 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-06-20 2024-07-12 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2024-06-20 2024-07-12 N
Create arrangements with other facilities to receive patients. Fire Safety 2024-06-20 2024-07-12 N
Develop a communication plan. Fire Safety 2024-06-20 2024-07-12 N
Establish emergency prep training and testing. Fire Safety 2024-06-20 2024-07-12 N
Establish staff and initial training requirements. Fire Safety 2024-06-20 2024-07-12 N
Conduct testing and exercise requirements. Fire Safety 2024-06-20 2024-07-12 N
Have properly located and lighted "Exit" signs. Fire Safety 2024-06-20 2024-07-12 N
Provide properly protected cooking facilities. Fire Safety 2024-06-20 2024-07-12 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2024-06-20 2024-07-12 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2024-06-20 2024-07-12 N
Install an approved automatic sprinkler system. Fire Safety 2024-06-20 2024-07-12 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-06-20 2024-07-12 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-06-20 2024-07-12 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-06-20 2024-07-12 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-06-20 2024-07-12 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2024-06-07 2024-07-10 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2024-06-07 2024-07-10 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-06-07 2024-07-10 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-06-07 2024-07-10 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-06-07 2024-07-10 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2024-06-07 2024-07-10 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2024-06-07 2024-07-10 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2024-06-07 2024-07-10 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-06-07 2024-07-10 N
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Health 2024-06-07 2024-07-10 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2024-06-07 2024-07-10 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2024-06-07 2024-07-10 N
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2024-06-07 2024-07-10 N
Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. Health 2024-06-07 2024-07-10 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2024-06-07 2024-07-10 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-06-07 2024-07-10 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2024-06-07 2024-07-10 Y
Provide enough food/fluids to maintain a resident's health. Health 2024-06-07 2024-07-10 Y
Provide or get specialized rehabilitative services as required for a resident. Health 2024-03-09 2024-03-19 Y
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2024-01-16 2024-02-05 Y
Provide activities to meet all resident's needs. Health 2024-01-16 2024-02-05 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-01-16 2024-02-05 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2024-01-16 2024-02-05 Y
Provide or obtain dental services for each resident. Health 2024-01-16 2024-02-05 Y
Reasonably accommodate the needs and preferences of each resident. Health 2023-12-05 2023-12-21 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-12-05 2023-12-21 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2023-12-05 2023-12-21 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2023-11-08 2023-11-10 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-10-21 2023-11-03 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2023-10-12 2023-10-20 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-10-12 2023-10-20 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-09-01 2023-09-19 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-09-01 2023-09-19 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-05-11 2023-06-05 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2023-05-11 2023-06-05 N
Develop a communication plan. Fire Safety 2023-05-11 2023-06-05 N
Establish emergency prep training and testing. Fire Safety 2023-05-11 2023-06-05 N
Establish staff and initial training requirements. Fire Safety 2023-05-11 2023-06-05 N
Conduct testing and exercise requirements. Fire Safety 2023-05-11 2023-06-05 N
Install a two-hour-resistant firewall separation. Fire Safety 2023-05-11 2023-06-05 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-05-11 2023-06-05 N
Provide properly protected cooking facilities. Fire Safety 2023-05-11 2023-06-05 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-05-11 2023-06-05 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-05-11 2023-06-05 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-05-11 2023-06-05 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-05-11 2023-06-05 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-05-11 2023-06-05 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2023-05-03 2023-05-19 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-05-03 2023-05-19 N
Respond appropriately to all alleged violations. Health 2023-05-03 2023-05-19 N
Provide activities to meet all resident's needs. Health 2023-05-03 2023-05-19 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-05-03 2023-05-19 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2023-05-03 2023-05-19 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-05-03 2023-05-19 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-05-03 2023-05-19 N
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Health 2023-05-03 2023-05-19 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2023-05-03 2023-05-19 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-11-02 2022-12-10 Y
Conduct testing and exercise requirements. Fire Safety 2022-06-24 2022-08-08 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-07-07 2022-08-01 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-07-07 2022-08-01 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-06-24 2022-07-15 N
Address patient/client population and determine types of services needed. Fire Safety 2022-06-24 2022-07-15 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2022-06-24 2022-07-15 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2022-06-24 2022-07-15 N
Develop a communication plan. Fire Safety 2022-06-24 2022-07-15 N
Establish emergency prep training and testing. Fire Safety 2022-06-24 2022-07-15 N
Establish staff and initial training requirements. Fire Safety 2022-06-24 2022-07-15 N
Have properly located and lighted "Exit" signs. Fire Safety 2022-06-24 2022-07-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-06-24 2022-07-15 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-06-24 2022-07-15 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-06-24 2022-07-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-06-24 2022-07-15 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2022-06-10 2022-06-25 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2022-06-10 2022-06-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-06-10 2022-06-25 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-06-10 2022-06-25 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2022-06-10 2022-06-25 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-05-03 2022-05-16 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-05-03 2022-05-16 Y
Provide and implement an infection prevention and control program. Health 2022-02-09 2022-03-25 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-02-09 2022-03-25 N
Perform COVID19 testing on residents and staff. Health 2022-02-09 2022-03-25 N
Report COVID19 data to residents and families. Health 2022-02-09 2022-03-08 N
Protect each resident from the wrongful use of the resident's belongings or money. Health 2021-12-28 2022-01-19 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2021-12-28 2022-01-19 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-12-28 2022-01-19 Y
Respond appropriately to all alleged violations. Health 2021-12-28 2022-01-19 Y
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-12-28 2022-01-19 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2021-12-28 2022-01-19 Y

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