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Deficiency Records for The Meadows On University
A list of the most recent deficiencies for The Meadows On University. 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 The Meadows On University. 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 properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-20 | 2024-03-05 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-02-20 | 2024-03-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-08 | 2024-03-01 | 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 | 2024-02-08 | 2024-03-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-08 | 2024-03-01 | 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 | 2024-02-08 | 2024-03-01 | 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 | 2023-08-21 | 2023-09-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-21 | 2023-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-21 | 2023-09-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-21 | 2023-09-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-21 | 2023-09-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-21 | 2023-09-15 | 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 | 2023-08-09 | 2023-09-08 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-09 | 2023-09-08 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-30 | 2022-12-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-30 | 2022-12-17 | 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 | 2022-08-30 | 2022-11-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-30 | 2022-10-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-30 | 2022-10-28 | Y |
| 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 | 2022-08-30 | 2022-10-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-30 | 2022-09-28 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-08-30 | 2022-09-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-30 | 2022-09-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-30 | 2022-09-28 | 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 | 2022-08-30 | 2022-09-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-30 | 2022-09-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-30 | 2022-09-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-30 | 2022-09-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-30 | 2022-09-28 | 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 | 2022-08-30 | 2022-09-28 | Y |
| Post nurse staffing information every day. | Health | 2022-08-30 | 2022-09-28 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2022-08-30 | 2022-09-28 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-08-30 | 2022-09-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-21 | 2022-06-14 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-21 | 2022-06-14 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-21 | 2022-06-14 | Y |
| 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 | 2022-04-21 | 2022-05-26 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-21 | 2022-05-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-21 | 2022-05-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-21 | 2022-05-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-21 | 2022-05-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-21 | 2022-05-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-05-24 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-21 | 2022-05-24 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-04-21 | 2022-05-24 | 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 | 2022-04-21 | 2022-05-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-21 | 2022-05-24 | 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 | 2022-04-21 | 2022-05-24 | Y |
| 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 | 2022-04-21 | 2022-05-24 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-21 | 2022-05-24 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-21 | 2022-05-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-05-24 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-27 | 2022-05-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-27 | 2022-05-24 | N |
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