ElderGrade

Inspection citations at Maclay Healthcare Center

185 citations on record, 12 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 46 2
2025 19 2
2024 67 3
2023 53 5
E June 7, 2024 Tag F0726 Complaint investigation Corrected Jul 2024

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

E June 7, 2024 Tag F0712 Complaint investigation Corrected Jul 2024

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

No actual harm, potential for more than minimal harm

J June 7, 2024 Tag F0600 Complaint investigation Corrected Jul 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety

D April 10, 2024 Tag F0684 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D April 10, 2024 Tag F0656 Complaint investigation Corrected Apr 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D February 23, 2024 Tag F0842 Complaint investigation Corrected Mar 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D January 25, 2024 Tag F0842 Complaint investigation Corrected Feb 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D January 25, 2024 Tag F0755 Complaint investigation Corrected Feb 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D January 25, 2024 Tag F0697 Complaint investigation Corrected Feb 2024

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

D January 25, 2024 Tag F0580 Complaint investigation Corrected Feb 2024

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

D January 25, 2024 Tag F0550 Complaint investigation Corrected Feb 2024

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E January 25, 2024 Tag F0880 Complaint investigation Corrected Feb 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

G December 4, 2023 Tag F0684 Complaint investigation Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Actual harm to a resident

G November 14, 2023 Tag F0689 Complaint investigation Corrected Dec 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D October 25, 2023 Tag F0656 Complaint investigation Corrected Nov 2023

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0804 Corrected Oct 2023

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0761 Corrected Oct 2023

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0758 Corrected Oct 2023

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0757 Corrected Oct 2023

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0755 Corrected Oct 2023

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0692 Corrected Oct 2023

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0689 Corrected Oct 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0688 Corrected Oct 2023

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0686 Corrected Oct 2023

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0677 Corrected Oct 2023

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0676 Corrected Oct 2023

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0657 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0655 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0645 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0641 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0609 Complaint investigation Corrected Oct 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0578 Corrected Oct 2023

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D October 6, 2023 Tag F0554 Corrected Oct 2023

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

E October 6, 2023 Tag F0925 Corrected Oct 2023

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

No actual harm, potential for more than minimal harm

E October 6, 2023 Tag F0880 Corrected Oct 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E October 6, 2023 Tag F0849 Corrected Oct 2023

Administration Deficiencies

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.

No actual harm, potential for more than minimal harm

E October 6, 2023 Tag F0812 Corrected Oct 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E October 6, 2023 Tag F0690 Corrected Oct 2023

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

E October 6, 2023 Tag F0658 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

E October 6, 2023 Tag F0656 Corrected Oct 2023

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.