A list of the most recent deficiencies for Mcgivney 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? |
|---|---|---|---|---|
| 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 | 2023-10-26 | 2023-11-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-26 | 2023-11-06 | 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 | 2023-10-26 | 2023-11-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-26 | 2023-11-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-26 | 2023-11-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-26 | 2023-11-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-22 | 2023-10-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-22 | 2023-10-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-22 | 2023-10-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-22 | 2023-10-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-22 | 2023-10-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-27 | 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 | 2023-09-22 | 2023-10-27 | 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 | 2023-09-22 | 2023-10-27 | 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 | 2023-09-22 | 2023-10-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-22 | 2023-10-27 | N |
| Post nurse staffing information every day. | Health | 2023-09-22 | 2023-10-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-22 | 2023-10-27 | 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 | 2023-09-22 | 2023-10-27 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-09-22 | 2023-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-22 | 2023-10-27 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-22 | 2023-10-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-22 | 2023-10-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-22 | 2023-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-10-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-22 | 2023-10-27 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-09-22 | 2023-10-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-22 | 2023-10-27 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-09-22 | 2023-10-27 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-09-22 | 2023-10-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-22 | 2023-10-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-14 | 2022-11-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-27 | 2022-10-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-27 | 2022-10-31 | 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 | 2022-09-27 | 2022-10-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-27 | 2022-10-31 | 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 | 2022-07-26 | 2022-10-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-26 | 2022-10-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-26 | 2022-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-26 | 2022-10-31 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-07-26 | 2022-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-26 | 2022-10-31 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-07-26 | 2022-10-31 | 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 | 2022-07-26 | 2022-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-26 | 2022-10-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-26 | 2022-10-31 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-26 | 2022-10-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-07-26 | 2022-10-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-15 | 2022-09-22 | 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 | 2022-08-15 | 2022-09-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-15 | 2022-09-22 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-25 | 2022-05-17 | Y |
| 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 | 2021-07-19 | 2021-08-09 | 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 | 2021-07-19 | 2021-08-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-07-19 | 2021-08-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-19 | 2021-08-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-19 | 2021-08-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-07-19 | 2021-08-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-19 | 2021-08-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-19 | 2021-08-09 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-07-19 | 2021-08-09 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-07-19 | 2021-08-06 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-06-11 | 2021-07-16 | 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 | 2021-06-11 | 2021-07-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-11 | 2021-07-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-11 | 2021-07-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-06-11 | 2021-07-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-11 | 2021-07-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-11 | 2021-07-16 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-06-11 | 2021-07-16 | N |
