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Deficiency Records for Meadowbrook Manor
A list of the most recent deficiencies for Meadowbrook Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Meadowbrook Manor. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-02 | 2024-07-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-02 | 2024-07-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-07-02 | 2024-07-18 | 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 | 2024-07-02 | 2024-07-18 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-07-02 | 2024-07-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-02 | 2024-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-02 | 2024-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-02 | 2024-07-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-02 | 2024-07-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-02 | 2024-07-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-02 | 2024-07-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-02 | 2024-07-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-27 | 2024-07-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-07-02 | 2024-07-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-06-27 | 2024-07-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-06-27 | 2024-07-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-27 | 2024-07-16 | 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 | 2024-06-27 | 2024-07-16 | 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 | 2024-06-27 | 2024-07-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-27 | 2024-07-16 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-06-27 | 2024-07-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-27 | 2024-07-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-06-27 | 2024-07-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-02 | 2024-07-16 | 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 | 2024-05-08 | 2024-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-18 | 2024-04-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-23 | 2024-03-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-23 | 2024-03-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-06 | 2023-11-28 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-20 | 2023-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-20 | 2023-11-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-20 | 2023-10-05 | 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 | 2023-09-20 | 2023-10-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-20 | 2023-10-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-20 | 2023-10-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-20 | 2023-10-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-09-20 | 2023-10-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-09-20 | 2023-10-05 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-09-14 | 2023-10-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-14 | 2023-10-04 | 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 | 2023-09-14 | 2023-10-04 | 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 | 2023-09-14 | 2023-10-04 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-14 | 2023-10-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-14 | 2023-10-04 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-09-14 | 2023-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-29 | 2023-02-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-08 | 2023-01-25 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-12-08 | 2023-01-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-12-08 | 2023-01-20 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-12-08 | 2023-01-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-08 | 2023-01-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-08 | 2023-01-05 | 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 | 2022-12-08 | 2023-01-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-08 | 2023-01-05 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-12-08 | 2022-12-30 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2022-12-08 | 2022-12-30 | 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 | 2022-12-08 | 2022-12-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-08 | 2022-12-29 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-12-08 | 2022-12-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2022-12-28 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-08 | 2022-12-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-12-08 | 2022-12-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-08 | 2022-12-10 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-12-08 | 2022-12-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-08 | 2022-12-08 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2022-12-08 | 2022-12-08 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2022-12-08 | 2022-12-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-02 | 2022-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-06-17 | Y |
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