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Deficiency Records for Maclay Healthcare Center
A list of the most recent deficiencies for Maclay Healthcare 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 Maclay Healthcare 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? |
---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-21 | 2024-09-16 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-18 | 2024-08-20 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-07 | 2024-07-15 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-07 | 2024-07-15 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-07 | 2024-07-15 | Y |
Respond appropriately to all alleged violations. | Health | 2024-06-07 | 2024-07-15 | Y |
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 | 2024-07-15 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-07 | 2024-07-15 | Y |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-06-07 | 2024-07-15 | Y |
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 | 2024-06-07 | 2024-07-15 | 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 | 2024-06-07 | 2024-07-15 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-07 | 2024-07-15 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-10 | 2024-04-27 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-10 | 2024-04-27 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-23 | 2024-03-06 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-02-16 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-25 | 2024-02-16 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-25 | 2024-02-16 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-25 | 2024-02-16 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-25 | 2024-02-16 | Y |
Provide and implement an infection prevention and control program. | Health | 2024-01-25 | 2024-02-16 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-04 | 2023-12-24 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-14 | 2023-12-14 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-25 | 2023-11-15 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-27 | 2023-10-31 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-27 | 2023-10-31 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-27 | 2023-10-31 | Y |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-27 | 2023-10-31 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-27 | 2023-10-31 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-07 | 2023-10-31 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-07 | 2023-10-31 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-10-31 | Y |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-09-07 | 2023-10-31 | Y |
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 | 2023-09-07 | 2023-10-31 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-07 | 2023-10-31 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-09-07 | 2023-10-31 | Y |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-11 | 2023-10-31 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-11 | 2023-10-31 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-10-31 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-06 | 2023-10-30 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-06 | 2023-10-30 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-06 | 2023-10-30 | N |
Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
Ensure each resident receives an accurate assessment. | Health | 2023-10-06 | 2023-10-30 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-06 | 2023-10-30 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-06 | 2023-10-30 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-06 | 2023-10-30 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-06 | 2023-10-30 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-06 | 2023-10-30 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-06 | 2023-10-30 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-06 | 2023-10-30 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-06 | 2023-10-30 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-06 | 2023-10-30 | N |
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-06 | 2023-10-30 | N |
Provide and implement an infection prevention and control program. | Health | 2023-10-06 | 2023-10-30 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-06 | 2023-10-30 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-06 | 2023-10-30 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-22 | 2023-10-15 | Y |
Ensure that residents are free from significant medication errors. | Health | 2023-09-29 | 2023-10-13 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-09-01 | 2023-09-15 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-23 | 2023-09-08 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-23 | 2023-09-08 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-14 | 2023-08-21 | 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 | 2023-07-27 | 2023-08-10 | Y |
Keep residents' personal and medical records private and confidential. | Health | 2023-07-19 | 2023-08-10 | Y |
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 | 2023-07-19 | 2023-08-10 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-30 | 2023-07-16 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-06-30 | 2023-07-16 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-21 | 2023-07-15 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-21 | 2023-07-15 | Y |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-21 | 2023-07-15 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-21 | 2023-07-15 | 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 | 2023-06-21 | 2023-07-15 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-21 | 2023-07-15 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-12 | 2023-05-30 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-12 | 2023-05-30 | 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 | 2023-04-27 | 2023-05-12 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-27 | 2023-05-12 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-04-11 | 2023-05-05 | Y |
Respond appropriately to all alleged violations. | Health | 2023-03-16 | 2023-04-04 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-23 | 2023-03-05 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-23 | 2023-03-05 | Y |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-23 | 2023-03-05 | Y |
Post nurse staffing information every day. | Health | 2023-02-21 | 2023-03-03 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-10 | 2023-03-03 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-19 | 2023-02-02 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-19 | 2023-02-02 | 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 | 2023-01-19 | 2023-02-02 | Y |
Post nurse staffing information every day. | Health | 2023-01-19 | 2023-02-02 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-01-19 | 2023-02-02 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-28 | 2023-01-17 | 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 | 2022-10-28 | 2023-01-17 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-21 | 2022-12-19 | Y |
Ensure that residents are free from significant medication errors. | Health | 2022-11-21 | 2022-12-19 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-28 | 2022-12-14 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | N |
Keep residents' personal and medical records private and confidential. | Health | 2022-10-28 | 2022-12-14 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-28 | 2022-12-14 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-28 | 2022-12-14 | N |
Ensure that residents are free from significant medication errors. | Health | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-28 | 2022-12-14 | N |
Provide and implement an infection prevention and control program. | Health | 2022-10-28 | 2022-12-14 | N |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-02 | 2022-12-14 | N |
Establish policies and procedures for volunteers. | Fire Safety | 2022-11-02 | 2022-12-14 | 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 | 2022-11-02 | 2022-12-14 | N |
Provide properly protected cooking facilities. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-21 | 2022-09-21 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-01 | 2022-09-18 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-08-10 | 2022-09-12 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-14 | 2022-08-24 | Y |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-14 | 2022-08-24 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-07-24 | 2022-08-03 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-05 | 2022-07-29 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-07-05 | 2022-07-29 | 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 | 2022-06-23 | 2022-07-01 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-21 | 2022-06-16 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-21 | 2022-06-16 | 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 | 2022-04-03 | 2022-04-27 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-03 | 2022-04-27 | Y |
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 | 2022-04-03 | 2022-04-27 | Y |
Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-04-03 | 2022-04-27 | Y |
Post nurse staffing information every day. | Health | 2022-02-15 | 2022-03-10 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-02-24 | 2022-03-07 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-27 | 2022-01-18 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-27 | 2022-01-18 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-26 | 2022-01-07 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-21 | 2021-11-01 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-21 | 2021-11-01 | Y |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-24 | 2019-09-19 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-24 | 2019-09-19 | N |
Ensure each resident receives an accurate assessment. | Health | 2019-08-24 | 2019-09-19 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-24 | 2019-09-19 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-24 | 2019-09-19 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-24 | 2019-09-19 | 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 | 2019-08-24 | 2019-09-19 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-24 | 2019-09-19 | 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 | 2019-08-24 | 2019-09-19 | N |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-08-24 | 2019-09-19 | N |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-08-24 | 2019-09-19 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-24 | 2019-09-19 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-29 | 2019-09-19 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-29 | 2019-09-19 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-29 | 2019-09-19 | N |
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