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Deficiency Records for Meadow Green Nursing and Rehabilitation Center
A list of the most recent deficiencies for Meadow Green Nursing and Rehabilitation 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 Green Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-13 | 2024-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-13 | 2024-05-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-13 | 2024-05-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-13 | 2024-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-13 | 2024-05-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-13 | 2024-05-15 | 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 | 2024-03-13 | 2024-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-13 | 2024-04-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-13 | 2024-04-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-21 | 2024-04-26 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-03-21 | 2024-04-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-21 | 2024-04-26 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-03-13 | 2024-04-23 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-13 | 2024-04-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-13 | 2024-04-23 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-13 | 2024-04-23 | 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 | 2024-03-13 | 2024-04-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-13 | 2024-04-23 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-03-13 | 2024-04-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-13 | 2024-04-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-13 | 2024-04-23 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-13 | 2024-04-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-13 | 2024-04-23 | 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 | 2024-03-13 | 2024-04-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-03-13 | 2024-04-23 | 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 | 2024-03-13 | 2024-04-23 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-13 | 2024-04-23 | 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 | 2024-03-13 | 2024-04-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-03-13 | 2024-04-23 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-13 | 2024-04-23 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-03-13 | 2024-04-23 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-03-13 | 2024-04-23 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-03-13 | 2024-04-23 | 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 | 2024-03-13 | 2024-04-23 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-03-13 | 2024-04-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-13 | 2024-04-23 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-03-13 | 2024-04-23 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-03-13 | 2024-04-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-11 | 2023-02-13 | 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 | 2023-01-11 | 2023-02-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-11 | 2023-02-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-11 | 2023-02-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-11 | 2023-02-13 | 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 | 2023-01-11 | 2023-02-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-11 | 2023-02-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-11 | 2023-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-13 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-22 | 2022-04-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-03-18 | 2021-04-08 | 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 | 2021-03-18 | 2021-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-18 | 2021-04-08 | N |
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