Deficiency Records for Maybrook Hills Rehabilitation and Healthcare Cente
Updated as of April 01, 2024
A list of the most recent deficiencies for Maybrook Hills Rehabilitation and Healthcare Cente. 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 receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-31 | 2024-01-09 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-10-31 | 2023-12-14 | N |
| Use approved construction type or materials. | Fire Safety | 2023-10-31 | 2023-12-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-31 | 2023-12-14 | 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 | 2023-10-31 | 2023-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-31 | 2023-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-31 | 2023-12-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-10-26 | 2023-12-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-26 | 2023-12-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-26 | 2023-12-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-26 | 2023-12-12 | 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 | 2023-10-26 | 2023-12-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-26 | 2023-12-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-26 | 2023-12-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-26 | 2023-12-12 | 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 | 2023-10-26 | 2023-12-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-26 | 2023-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-12-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-26 | 2023-12-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-26 | 2023-12-12 | N |
| Keep all essential equipment working safely. | Health | 2023-10-26 | 2023-12-12 | 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 | 2023-05-08 | 2023-05-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-27 | 2023-01-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-27 | 2023-01-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-20 | 2022-11-21 | 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 | 2022-10-20 | 2022-11-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-20 | 2022-11-21 | 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 | 2022-10-20 | 2022-11-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-20 | 2022-11-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-20 | 2022-11-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-20 | 2022-11-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-20 | 2022-11-21 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-25 | 2022-11-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-03 | 2022-08-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-03 | 2022-08-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-09 | 2022-07-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-16 | 2022-03-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-21 | 2022-02-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-21 | 2022-02-03 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-10-27 | 2021-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-27 | 2021-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-27 | 2021-12-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-27 | 2021-12-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-10-27 | 2021-12-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-27 | 2021-12-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-21 | 2021-11-30 | 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 | 2021-10-21 | 2021-11-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-21 | 2021-11-30 | 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 | 2021-10-21 | 2021-11-30 | 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 | 2021-10-21 | 2021-11-30 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-10-21 | 2021-11-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-21 | 2021-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-11-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-21 | 2021-11-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-21 | 2021-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-21 | 2021-11-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-27 | 2021-08-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-27 | 2021-08-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-19 | 2021-08-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-07 | 2021-05-17 | Y |
