A list of the most recent deficiencies for Maclay Healthcare 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-23 | 2024-03-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-02-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-25 | 2024-02-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-25 | 2024-02-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-25 | 2024-02-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-25 | 2024-02-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-25 | 2024-02-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-04 | 2023-12-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-14 | 2023-12-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-25 | 2023-11-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-27 | 2023-10-31 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-27 | 2023-10-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-27 | 2023-10-31 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-27 | 2023-10-31 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-27 | 2023-10-31 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-07 | 2023-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-07 | 2023-10-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-10-31 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-09-07 | 2023-10-31 | Y |
| 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 | 2023-09-07 | 2023-10-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-07 | 2023-10-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-07 | 2023-10-31 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-11 | 2023-10-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-11 | 2023-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-10-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-06 | 2023-10-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-06 | 2023-10-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-06 | 2023-10-30 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-06 | 2023-10-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-06 | 2023-10-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-06 | 2023-10-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-06 | 2023-10-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-06 | 2023-10-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-06 | 2023-10-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-06 | 2023-10-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-06 | 2023-10-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | 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 | 2023-10-06 | 2023-10-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-06 | 2023-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-06 | 2023-10-30 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-06 | 2023-10-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-06 | 2023-10-30 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-06 | 2023-10-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-06 | 2023-10-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-22 | 2023-10-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-29 | 2023-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-01 | 2023-09-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-23 | 2023-09-08 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-23 | 2023-09-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-14 | 2023-08-21 | 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 | 2023-07-27 | 2023-08-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-19 | 2023-08-10 | 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 | 2023-07-19 | 2023-08-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-30 | 2023-07-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-30 | 2023-07-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-21 | 2023-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-21 | 2023-07-15 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-21 | 2023-07-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-21 | 2023-07-15 | 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 | 2023-06-21 | 2023-07-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-21 | 2023-07-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-12 | 2023-05-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-12 | 2023-05-30 | 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 | 2023-04-27 | 2023-05-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-27 | 2023-05-12 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-04-11 | 2023-05-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-23 | 2023-03-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-23 | 2023-03-05 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-23 | 2023-03-05 | Y |
| Post nurse staffing information every day. | Health | 2023-02-21 | 2023-03-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-10 | 2023-03-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-19 | 2023-02-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-19 | 2023-02-02 | 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 | 2023-01-19 | 2023-02-02 | Y |
| Post nurse staffing information every day. | Health | 2023-01-19 | 2023-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-19 | 2023-02-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-28 | 2023-01-17 | 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 | 2022-10-28 | 2023-01-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-21 | 2022-12-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-21 | 2022-12-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-28 | 2022-12-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-10-28 | 2022-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-28 | 2022-12-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-28 | 2022-12-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-28 | 2022-12-14 | 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 | 2022-10-28 | 2022-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-28 | 2022-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-28 | 2022-12-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-02 | 2022-12-14 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-11-02 | 2022-12-14 | 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 | 2022-11-02 | 2022-12-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-02 | 2022-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-21 | 2022-09-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-01 | 2022-09-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-10 | 2022-09-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-14 | 2022-08-24 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-14 | 2022-08-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-24 | 2022-08-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-05 | 2022-07-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-05 | 2022-07-29 | 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 | 2022-06-23 | 2022-07-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-21 | 2022-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-21 | 2022-06-16 | 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 | 2022-04-03 | 2022-04-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-03 | 2022-04-27 | Y |
| 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 | 2022-04-03 | 2022-04-27 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-04-03 | 2022-04-27 | Y |
| Post nurse staffing information every day. | Health | 2022-02-15 | 2022-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-24 | 2022-03-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-27 | 2022-01-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-27 | 2022-01-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-26 | 2022-01-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-21 | 2021-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-21 | 2021-11-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-10 | 2021-10-12 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-24 | 2019-09-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-24 | 2019-09-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-24 | 2019-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-24 | 2019-09-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-24 | 2019-09-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-24 | 2019-09-19 | 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 | 2019-08-24 | 2019-09-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-24 | 2019-09-19 | 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 | 2019-08-24 | 2019-09-19 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-08-24 | 2019-09-19 | 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 | 2019-08-24 | 2019-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-24 | 2019-09-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-29 | 2019-09-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-29 | 2019-09-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-29 | 2019-09-19 | N |
