A list of the most recent deficiencies for Majestic Care of West Allen. 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 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 | 2023-11-28 | 2023-12-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-22 | 2023-09-04 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Develop a communication plan. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-31 | 2023-09-01 | 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 | 2023-07-31 | 2023-09-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-31 | 2023-09-01 | 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 | 2023-07-31 | 2023-09-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-06-29 | 2023-08-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-20 | 2023-08-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-19 | 2023-01-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-21 | 2022-10-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-21 | 2022-10-17 | N |
| Provide activities to meet all resident's needs. | Health | 2022-09-21 | 2022-10-17 | 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 | 2022-09-21 | 2022-10-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-21 | 2022-10-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-21 | 2022-10-17 | 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 | 2022-09-21 | 2022-10-17 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-09-21 | 2022-10-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-21 | 2022-10-17 | N |
| Dispose of garbage and refuse properly. | Health | 2022-09-21 | 2022-10-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-21 | 2022-10-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-21 | 2022-10-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-25 | 2022-03-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-25 | 2022-03-09 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-02-25 | 2022-03-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-20 | 2022-01-25 | Y |
| Install proper backup exit lighting. | Fire Safety | 2021-08-09 | 2021-09-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-09 | 2021-09-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-09 | 2021-09-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-09 | 2021-08-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-09 | 2021-08-25 | 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 | 2021-08-09 | 2021-08-25 | 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 | 2021-08-09 | 2021-08-25 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-08-09 | 2021-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-09 | 2021-08-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-09 | 2021-08-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-09 | 2021-08-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-09 | 2021-08-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-09 | 2021-08-25 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-08-09 | 2021-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-09 | 2021-08-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-16 | 2021-07-29 | 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 | 2021-07-16 | 2021-07-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-16 | 2021-07-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-16 | 2021-07-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-16 | 2021-07-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-07-16 | 2021-07-29 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-07-16 | 2021-07-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-16 | 2021-07-29 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-16 | 2021-07-29 | 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 | 2021-07-16 | 2021-07-29 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-07-16 | 2021-07-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-16 | 2021-07-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-16 | 2021-07-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-24 | 2021-04-09 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-03-24 | 2021-04-09 | Y |
