A list of the most recent deficiencies for Majestic Care of Whitehall. 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? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-10-13 | 2022-11-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-13 | 2022-11-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-10-13 | 2022-11-18 | 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 | 2022-10-13 | 2022-11-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-13 | 2022-11-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-13 | 2022-11-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-13 | 2022-11-18 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-13 | 2022-11-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-10-13 | 2022-11-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-10-13 | 2022-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-13 | 2022-11-18 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-13 | 2022-11-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-13 | 2022-11-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-13 | 2022-11-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-13 | 2022-11-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-13 | 2022-11-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-13 | 2022-11-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-13 | 2022-11-18 | 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 | 2022-10-13 | 2022-11-18 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-10-13 | 2022-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-13 | 2022-11-18 | 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 | 2022-10-13 | 2022-11-18 | 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 | 2022-11-16 | 2022-11-18 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-11-16 | 2022-11-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-16 | 2022-11-18 | Y |
| Provide appropriate foot care. | Health | 2022-11-16 | 2022-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-16 | 2022-11-18 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-16 | 2022-11-18 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-29 | 2022-11-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-29 | 2022-11-18 | 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 | 2022-08-30 | 2022-09-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-30 | 2022-09-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-30 | 2022-09-07 | Y |
| 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 | 2022-08-30 | 2022-09-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-06 | 2022-06-16 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-06 | 2022-06-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-06 | 2022-06-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-06 | 2022-06-16 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-06-06 | 2022-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-29 | 2022-06-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-12 | 2022-06-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-12 | 2022-06-16 | 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 | 2022-04-12 | 2022-06-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-17 | 2022-06-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-17 | 2022-06-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-13 | 2022-01-28 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-13 | 2022-01-28 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-01-13 | 2022-01-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-13 | 2022-01-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-13 | 2022-01-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-03 | 2022-01-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-03 | 2022-01-28 | 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 | 2022-01-03 | 2022-01-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-03 | 2022-01-28 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2021-11-24 | 2021-12-02 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-11-24 | 2021-12-02 | 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 | 2021-11-24 | 2021-12-02 | Y |
| Provide or obtain dental services for each resident. | Health | 2021-11-24 | 2021-12-02 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-11-24 | 2021-12-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-30 | 2021-08-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-30 | 2021-08-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-30 | 2021-08-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-09 | 2021-08-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-09 | 2021-08-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-09 | 2021-08-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-09 | 2021-08-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-09 | 2021-08-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-17 | 2021-08-02 | 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 | 2021-05-17 | 2021-08-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-13 | 2021-08-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-13 | 2021-08-02 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-20 | 2020-03-31 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-11-21 | 2019-12-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-21 | 2019-12-05 | 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 | 2019-11-21 | 2019-12-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-21 | 2019-12-05 | 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 | 2019-11-21 | 2019-12-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-21 | 2019-12-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-11-21 | 2019-12-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-21 | 2019-12-05 | 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 | 2019-11-21 | 2019-12-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-21 | 2019-12-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-21 | 2019-12-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-21 | 2019-12-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-21 | 2019-12-05 | 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 | 2019-11-21 | 2019-12-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-21 | 2019-12-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-21 | 2019-12-05 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2019-11-21 | 2019-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-21 | 2019-12-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-11-20 | 2019-12-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-20 | 2019-12-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-20 | 2019-12-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-20 | 2019-12-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-20 | 2019-12-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-20 | 2019-12-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-20 | 2019-12-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-20 | 2019-12-05 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-09-20 | 2018-11-13 | 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 | 2018-09-20 | 2018-11-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-20 | 2018-11-13 | 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 | 2018-09-20 | 2018-11-13 | 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 | 2018-09-20 | 2018-11-13 | N |
| Provide or obtain dental services for each resident. | Health | 2018-09-20 | 2018-11-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-20 | 2018-11-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-18 | 2018-11-13 | 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 | 2018-09-18 | 2018-11-13 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-18 | 2018-11-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-20 | 2018-10-17 | N |
