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Deficiency Records for Mckay Healthcare and Rehab Ctr

A list of the most recent deficiencies for Mckay Healthcare and Rehab Ctr. 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 Mckay Healthcare and Rehab Ctr. 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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-08-22 2024-09-24 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-08-22 2024-09-24 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-06-26 2024-07-23 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-02-07 2024-05-02 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-04-25 2024-05-01 Y
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-02-07 2024-04-30 N
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Health 2024-02-09 2024-03-25 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 2024-02-09 2024-03-25 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2024-02-09 2024-03-25 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-02-09 2024-03-25 N
Respond appropriately to all alleged violations. Health 2024-02-09 2024-03-25 N
Assess the resident when there is a significant change in condition Health 2024-02-09 2024-03-25 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2024-02-09 2024-03-25 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 2024-02-09 2024-03-25 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-02-09 2024-03-25 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 2024-02-09 2024-03-25 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-02-09 2024-03-25 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 2024-02-09 2024-03-25 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2024-02-09 2024-03-25 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 2024-02-09 2024-03-25 N
Ensure medication error rates are not 5 percent or greater. Health 2024-02-09 2024-03-25 N
Ensure that residents are free from significant medication errors. Health 2024-02-09 2024-03-25 N
Provide or obtain dental services for each resident. Health 2024-02-09 2024-03-25 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2024-02-09 2024-03-25 N
Provide and implement an infection prevention and control program. Health 2024-02-09 2024-03-25 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2024-02-07 2024-03-21 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-02-07 2024-03-12 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2024-02-07 2024-03-12 N
Address patient/client population and determine types of services needed. Fire Safety 2024-02-07 2024-03-12 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2024-02-07 2024-03-12 N
Establish policies and procedures including evacuation. Fire Safety 2024-02-07 2024-03-12 N
Establish roles under a Waiver declared by secretary. Fire Safety 2024-02-07 2024-03-12 N
List the names and contact information of those in the facility. Fire Safety 2024-02-07 2024-03-12 N
Provide emergency officials' contact information. Fire Safety 2024-02-07 2024-03-12 N
Establish emergency prep training and testing. Fire Safety 2024-02-07 2024-03-12 N
Establish staff and initial training requirements. Fire Safety 2024-02-07 2024-03-12 N
Conduct testing and exercise requirements. Fire Safety 2024-02-07 2024-03-12 N
Meet other general requirements. Fire Safety 2024-02-07 2024-03-12 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2024-02-07 2024-03-12 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2024-02-07 2024-03-12 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-02-07 2024-03-12 N
Have properly located and lighted "Exit" signs. Fire Safety 2024-02-07 2024-03-12 N
Provide properly protected cooking facilities. Fire Safety 2024-02-07 2024-03-12 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2024-02-07 2024-03-12 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-02-07 2024-03-12 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-02-07 2024-03-12 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-02-07 2024-03-12 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-02-07 2024-03-12 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-02-07 2024-03-12 N
Have an externally vented heating system. Fire Safety 2024-02-07 2024-03-12 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-02-07 2024-03-12 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-02-07 2024-03-12 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-02-07 2024-03-12 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2024-02-07 2024-03-12 N
Have proper medical gas storage and administration areas. Fire Safety 2024-02-07 2024-03-12 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2024-02-07 2024-03-12 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-08-23 2023-09-15 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-02-24 2023-03-31 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-01-25 2023-03-10 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 2023-01-25 2023-03-10 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-01-25 2023-03-10 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-01-25 2023-03-10 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-25 2023-03-10 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-01-25 2023-03-10 N
Provide and implement an infection prevention and control program. Health 2023-01-25 2023-03-10 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-01-25 2023-02-27 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2023-01-25 2023-02-27 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2023-01-25 2023-02-27 N
Establish roles under a Waiver declared by secretary. Fire Safety 2023-01-25 2023-02-27 N
Establish methods for sharing information. Fire Safety 2023-01-25 2023-02-27 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2023-01-25 2023-02-27 N
Provide family notifications of emergency plan. Fire Safety 2023-01-25 2023-02-27 N
Conduct testing and exercise requirements. Fire Safety 2023-01-25 2023-02-27 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-01-25 2023-02-25 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-01-25 2023-02-23 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2023-01-25 2023-02-21 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-01-25 2023-02-15 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-01-25 2023-02-03 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-01-25 2023-01-30 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2022-10-26 2022-11-22 Y
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2022-10-26 2022-11-22 Y
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2022-10-26 2022-11-22 Y
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2022-10-26 2022-11-22 Y
Respond appropriately to all alleged violations. Health 2022-10-17 2022-11-18 Y
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 2022-10-26 2022-11-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-10-26 2022-11-15 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-10-26 2022-11-15 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-08-22 2022-10-21 Y
Provide and implement an infection prevention and control program. Health 2022-06-08 2022-07-08 Y
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 2019-10-31 2019-12-13 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-10-31 2019-12-13 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2019-10-31 2019-12-13 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2019-10-31 2019-12-13 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-10-31 2019-12-13 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 2019-10-31 2019-12-13 N
Observe each nurse aide's job performance and give regular training. Health 2019-10-31 2019-12-13 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2019-10-31 2019-12-13 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 2019-10-31 2019-12-13 N
Provide and implement an infection prevention and control program. Health 2019-10-31 2019-12-13 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2019-10-30 2019-12-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-10-30 2019-12-13 N
Use approved construction type or materials. Fire Safety 2019-10-30 2019-11-13 N

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