Deficiency Records for Maclay Healthcare Center
Updated as of October 01, 2020
This is not the most recent data for Maclay Healthcare Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-08-05 | 2019-08-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-28 | 2019-06-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-28 | 2019-06-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-12 | 2019-04-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-03-08 | 2019-03-31 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-02-21 | 2019-03-05 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-02-01 | 2019-02-28 | Y |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-02-01 | 2019-02-28 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-01 | 2019-02-28 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-01 | 2019-02-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-13 | 2019-02-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-02-13 | 2019-02-25 | 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 | 2019-02-14 | 2019-02-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-04 | 2019-02-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-01-14 | 2019-01-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-14 | 2019-01-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-12-28 | 2019-01-06 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-16 | 2019-01-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-11-16 | 2019-01-02 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2018-11-29 | 2018-12-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-21 | 2018-11-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-11-21 | 2018-11-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-03 | 2018-11-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-25 | 2018-11-27 | 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 | 2018-10-25 | 2018-11-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-25 | 2018-11-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-23 | 2018-10-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-29 | 2018-09-26 | 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 | 2018-08-29 | 2018-09-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-29 | 2018-09-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-24 | 2018-09-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-24 | 2018-09-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-24 | 2018-09-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-24 | 2018-09-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-24 | 2018-09-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-24 | 2018-09-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-24 | 2018-09-26 | 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 | 2018-08-24 | 2018-09-26 | 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 | 2018-08-24 | 2018-09-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-19 | 2018-07-25 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-06-27 | 2018-06-29 | Y |
| 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 | 2018-06-27 | 2018-06-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2018-01-02 | 2018-01-10 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-08-11 | 2017-11-03 | 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 | 2017-08-11 | 2017-11-03 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-11 | 2017-11-03 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-11 | 2017-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-12 | 2017-11-01 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-12 | 2017-11-01 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-08-11 | 2017-10-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-08-11 | 2017-10-12 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-08-11 | 2017-10-12 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-11 | 2017-10-12 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-08-11 | 2017-10-12 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-11 | 2017-10-12 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2017-08-11 | 2017-10-12 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-08-11 | 2017-10-12 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-08-11 | 2017-10-12 | Y |
| Meet other general requirements. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-08-14 | 2017-09-06 | 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 | 2017-08-14 | 2017-09-06 | N |
| Construct fire resistant interior walls. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-08-14 | 2017-09-06 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-06-26 | 2017-07-07 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-06-26 | 2017-07-07 | Y |
