A list of the most recent deficiencies for Mckay Healthcare and Rehab Ctr. 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? |
|---|---|---|---|---|
| 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 | 2024-02-09 | 2024-03-25 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-09 | 2024-03-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-09 | 2024-03-25 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-09 | 2024-03-25 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-02-09 | 2024-03-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-09 | 2024-03-25 | 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 | 2024-02-09 | 2024-03-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-09 | 2024-03-25 | 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 | 2024-02-09 | 2024-03-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-09 | 2024-03-25 | 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 | 2024-02-09 | 2024-03-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-09 | 2024-03-25 | 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 | 2024-02-09 | 2024-03-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-09 | 2024-03-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-09 | 2024-03-25 | N |
| Provide or obtain dental services for each resident. | Health | 2024-02-09 | 2024-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-09 | 2024-03-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Meet other general requirements. | Fire Safety | 2024-02-07 | 2024-03-12 | 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 | 2024-02-07 | 2024-03-12 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Have an externally vented heating system. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-02-07 | 2024-03-12 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-02-09 | 2024-03-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-02-09 | 2024-03-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-23 | 2023-09-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-24 | 2023-03-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-25 | 2023-03-10 | 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 | 2023-01-25 | 2023-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-25 | 2023-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-25 | 2023-03-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-25 | 2023-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-25 | 2023-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-25 | 2023-03-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-25 | 2023-02-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-01-25 | 2023-02-27 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-01-25 | 2023-02-27 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-01-25 | 2023-02-27 | N |
| Establish methods for sharing information. | Fire Safety | 2023-01-25 | 2023-02-27 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-01-25 | 2023-02-27 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-01-25 | 2023-02-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-25 | 2023-02-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-25 | 2023-02-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-25 | 2023-02-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-25 | 2023-02-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-25 | 2023-02-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-25 | 2023-02-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-25 | 2023-01-30 | N |
| 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 | 2022-10-26 | 2022-11-22 | 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 | 2022-10-26 | 2022-11-22 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-26 | 2022-11-22 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-10-26 | 2022-11-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-17 | 2022-11-18 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-10-26 | 2022-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-11-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-26 | 2022-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-22 | 2022-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-08 | 2022-07-08 | 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 | 2019-10-31 | 2019-12-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-31 | 2019-12-13 | 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 | 2019-10-31 | 2019-12-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-31 | 2019-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-12-13 | 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 | 2019-10-31 | 2019-12-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-31 | 2019-12-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-10-31 | 2019-12-13 | 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 | 2019-10-31 | 2019-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-12-13 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-10-30 | 2019-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-30 | 2019-12-13 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-30 | 2019-11-13 | N |
