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Deficiency Records for Majestic Care of Deming Park
A list of the most recent deficiencies for Majestic Care of Deming Park. 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 Majestic Care of Deming Park. 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? |
|---|---|---|---|---|
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-08 | 2024-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-08 | 2024-07-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Develop a communication plan. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-08 | 2024-07-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-07-08 | 2024-07-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-06-07 | 2024-06-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-06-07 | 2024-06-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-07 | 2024-06-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-06-07 | 2024-06-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-07 | 2024-06-28 | N |
| 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 | 2024-06-07 | 2024-06-28 | 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 | 2024-06-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-08 | 2024-03-29 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-03-08 | 2024-03-29 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-01 | 2023-05-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-01 | 2023-05-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-01 | 2023-05-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-01 | 2023-05-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-01 | 2023-05-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-01 | 2023-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-01 | 2023-05-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-01 | 2023-05-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-01 | 2023-05-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-01 | 2023-05-10 | N |
| 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 | 2023-04-06 | 2023-05-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-06 | 2023-05-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-06 | 2023-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-06 | 2023-05-01 | N |
| 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 | 2023-04-06 | 2023-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-06 | 2023-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-05 | 2022-04-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-14 | 2022-03-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-14 | 2022-03-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-14 | 2022-03-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-14 | 2022-03-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-14 | 2022-02-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-14 | 2022-02-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-14 | 2022-02-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-02-14 | 2022-02-19 | N |
| Develop a communication plan. | Fire Safety | 2022-02-14 | 2022-02-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-02-14 | 2022-02-19 | 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 | 2022-01-25 | 2022-02-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-25 | 2022-02-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-25 | 2022-02-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-25 | 2022-02-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-25 | 2022-02-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-25 | 2022-02-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-01-25 | 2022-02-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-25 | 2022-02-16 | 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 | 2022-01-25 | 2022-02-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-25 | 2022-02-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-25 | 2022-02-16 | N |
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