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Deficiency Records for Meadow Park Rehabilitation and Healthcare Center
A list of the most recent deficiencies for Meadow Park Rehabilitation and Healthcare Center. 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 Meadow Park Rehabilitation and 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-31 | 2022-09-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-31 | 2022-09-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-31 | 2022-09-22 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-31 | 2022-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-31 | 2022-09-22 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-08-31 | 2022-09-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-23 | 2022-09-16 | 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 | 2022-06-23 | 2022-09-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-23 | 2022-09-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-23 | 2022-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-23 | 2022-09-16 | 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 | 2022-06-23 | 2022-09-16 | 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 | 2022-06-23 | 2022-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-23 | 2022-09-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-23 | 2022-09-16 | 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 | 2022-06-23 | 2022-09-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-23 | 2022-08-03 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-23 | 2022-08-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-23 | 2022-08-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-23 | 2022-08-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-23 | 2022-08-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-23 | 2022-08-03 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-06-23 | 2022-08-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-23 | 2022-08-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-23 | 2022-08-03 | 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 | 2022-06-23 | 2022-08-03 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-23 | 2022-08-03 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-09 | 2022-07-28 | 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 | 2022-06-09 | 2022-07-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-09 | 2022-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-09 | 2022-07-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-09 | 2022-07-28 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2022-06-09 | 2022-07-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-06-09 | 2022-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-12 | 2022-01-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-12 | 2021-12-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-12 | 2021-12-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-12 | 2021-12-28 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-11-12 | 2021-12-28 | 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 | 2021-11-12 | 2021-12-28 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-11-12 | 2021-12-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-25 | 2021-12-09 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2021-10-25 | 2021-12-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-25 | 2021-12-09 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-25 | 2021-12-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-25 | 2021-12-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-25 | 2021-12-09 | 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 | 2021-10-25 | 2021-12-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-25 | 2021-12-09 | 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 | 2021-10-25 | 2021-12-09 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-25 | 2021-12-09 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-10-25 | 2021-12-09 | Y |
| Post nurse staffing information every day. | Health | 2021-10-25 | 2021-12-09 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-25 | 2021-12-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-25 | 2021-12-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-25 | 2021-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-25 | 2021-12-09 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-25 | 2021-12-09 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-25 | 2021-12-09 | Y |
| 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 | 2021-10-25 | 2021-12-09 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-04-17 | 2019-06-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-17 | 2019-06-14 | N |
| 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 | 2019-04-17 | 2019-06-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-17 | 2019-06-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-17 | 2019-06-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-17 | 2019-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-17 | 2019-06-14 | 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 | 2019-04-17 | 2019-06-14 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-17 | 2019-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-17 | 2019-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-17 | 2019-06-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-17 | 2019-06-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-17 | 2019-06-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-04-17 | 2019-06-14 | N |
| 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 | 2019-04-17 | 2019-06-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-17 | 2019-06-14 | N |
| 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 | 2019-04-17 | 2019-06-14 | 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 | 2019-04-17 | 2019-06-14 | 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 | 2019-04-17 | 2019-06-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-17 | 2019-06-14 | 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 | 2019-04-17 | 2019-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-17 | 2019-06-14 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2019-04-17 | 2019-06-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-17 | 2019-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-07 | 2019-06-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-07 | 2019-06-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-13 | 2018-01-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-12-13 | 2018-01-27 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2017-12-13 | 2018-01-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2017-12-13 | 2018-01-27 | N |
| 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 | 2017-12-13 | 2018-01-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2017-12-13 | 2018-01-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-13 | 2018-01-27 | 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 | 2017-12-13 | 2018-01-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2017-12-13 | 2018-01-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-13 | 2018-01-27 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2017-12-13 | 2018-01-27 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2017-12-13 | 2018-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-13 | 2018-01-27 | N |
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