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Deficiency Records for Meadowbrook Rehabilitation Hospital

A list of the most recent deficiencies for Meadowbrook Rehabilitation Hospital. 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 Rehabilitation Hospital. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-01-25 2024-03-05 Y
Reasonably accommodate the needs and preferences of each resident. Health 2024-01-25 2024-03-05 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-01-25 2024-03-05 Y
Respond appropriately to all alleged violations. Health 2024-01-25 2024-03-05 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-01-25 2024-03-05 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 2024-01-25 2024-03-05 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-01-25 2024-03-05 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-01-25 2024-03-05 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-01-25 2024-03-05 Y
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 2024-01-25 2024-03-05 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-01-25 2024-03-05 Y
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2024-01-25 2024-03-05 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 2024-01-25 2024-03-05 Y
Observe each nurse aide's job performance and give regular training. Health 2024-01-25 2024-03-05 Y
Post nurse staffing information every day. Health 2024-01-25 2024-03-05 Y
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2024-01-25 2024-03-05 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-01-25 2024-03-05 Y
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 2024-01-25 2024-03-05 Y
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 2024-01-25 2024-03-05 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-01-25 2024-03-05 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-01-25 2024-03-05 Y
Keep all essential equipment working safely. Health 2024-01-25 2024-03-05 Y
Have simulated fire drills held at unexpected times. Fire Safety 2024-02-07 2024-02-19 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-02-07 2024-02-19 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-02-07 2024-02-14 N
Use approved construction type or materials. Fire Safety 2024-02-07 2024-02-08 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-02-07 2024-02-08 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-02-07 2024-02-08 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-02-07 2024-02-08 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-03-01 2023-03-28 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-01-18 2023-01-18 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-12-27 2023-01-16 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2022-12-27 2023-01-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-18 2023-01-04 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-12-08 2023-01-03 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Health 2022-12-08 2023-01-03 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2022-12-08 2023-01-03 Y
Provide and implement an infection prevention and control program. Health 2022-07-25 2022-08-22 Y
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-04-06 2022-06-16 N
Reasonably accommodate the needs and preferences of each resident. Health 2022-03-16 2022-04-21 Y
Ensure each resident receives an accurate assessment. Health 2022-03-16 2022-04-21 Y
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2022-03-16 2022-04-21 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-03-16 2022-04-21 Y
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 2022-03-16 2022-04-21 Y
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-03-16 2022-04-21 Y
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 2022-03-16 2022-04-21 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-03-16 2022-04-21 Y
Provide and implement an infection prevention and control program. Health 2022-03-16 2022-04-21 Y
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 2022-04-06 2022-04-18 N
Install an approved automatic sprinkler system. Fire Safety 2022-04-06 2022-04-18 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-04-06 2022-04-18 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-04-06 2022-04-18 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-04-06 2022-04-18 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 2021-02-17 2021-03-18 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2021-02-17 2021-03-18 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 2021-02-17 2021-03-18 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2021-02-17 2021-03-18 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 2021-02-17 2021-03-18 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-02-17 2021-03-18 N
Provide and implement an infection prevention and control program. Health 2021-02-17 2021-03-18 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2020-03-17 2020-05-07 N
Establish policies and procedures for volunteers. Fire Safety 2020-03-17 2020-05-07 N
Establish roles under a Waiver declared by secretary. Fire Safety 2020-03-17 2020-05-07 N
Use approved construction type or materials. Fire Safety 2020-03-17 2020-05-07 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2020-03-17 2020-05-07 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 2020-03-17 2020-05-07 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2020-03-17 2020-05-07 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2020-03-17 2020-05-07 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-03-17 2020-05-07 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2020-03-17 2020-05-07 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-03-17 2020-05-07 N
Ensure proper usage of power strips and extension cords. Fire Safety 2020-03-17 2020-05-07 N
Have proper medical gas storage and administration areas. Fire Safety 2020-03-17 2020-05-07 N

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