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Deficiency Records for Meadow Park Care
A list of the most recent deficiencies for Meadow Park Care. 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 Care. 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? |
|---|---|---|---|---|
| Meet other general requirements that are deficient. | Fire Safety | 2024-06-05 | 2024-07-10 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-22 | 2024-03-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-22 | 2024-03-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-12 | 2023-10-25 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-12 | 2023-10-25 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-12 | 2023-10-25 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-12 | 2023-10-25 | 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 | 2023-09-12 | 2023-10-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-12 | 2023-10-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-12 | 2023-10-25 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-09-12 | 2023-10-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-12 | 2023-10-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-12 | 2023-10-25 | 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 | 2023-09-12 | 2023-10-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-12 | 2023-10-25 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-09-12 | 2023-10-25 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-09-12 | 2023-10-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-12 | 2023-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-12 | 2023-10-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-12 | 2023-10-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-12 | 2023-10-25 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-12 | 2023-10-25 | 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 | 2023-09-12 | 2023-10-25 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-09-12 | 2023-10-25 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-09-12 | 2023-10-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-12 | 2023-10-25 | Y |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-09-12 | 2023-10-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-12 | 2023-10-25 | Y |
| Keep all essential equipment working safely. | Health | 2023-09-12 | 2023-10-25 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-07 | 2023-10-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-03 | 2023-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-03 | 2023-03-22 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-29 | 2022-10-10 | 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 | 2022-08-29 | 2022-10-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-29 | 2022-10-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-29 | 2022-10-10 | 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 | 2022-08-29 | 2022-10-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-29 | 2022-10-10 | 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 | 2022-08-29 | 2022-10-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-29 | 2022-10-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-29 | 2022-10-10 | 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 | 2022-08-29 | 2022-10-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-29 | 2022-10-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-29 | 2022-10-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-29 | 2022-10-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-29 | 2022-10-10 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-08-24 | 2022-09-30 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-08-24 | 2022-09-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-24 | 2022-09-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-08-24 | 2022-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-24 | 2022-09-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-24 | 2022-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-24 | 2022-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-24 | 2022-09-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-24 | 2022-09-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-21 | 2022-07-29 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-06-21 | 2022-07-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-21 | 2022-07-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-21 | 2022-07-29 | 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 | 2022-06-21 | 2022-07-29 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2022-06-21 | 2022-07-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-30 | 2019-01-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-11-30 | 2019-01-08 | 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 | 2018-11-30 | 2019-01-08 | 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 | 2018-11-30 | 2019-01-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-30 | 2019-01-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-30 | 2019-01-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-30 | 2019-01-08 | 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 | 2018-11-30 | 2019-01-08 | 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 | 2018-11-30 | 2019-01-08 | 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 | 2018-11-30 | 2019-01-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-30 | 2019-01-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-12-05 | 2019-01-08 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-12-05 | 2019-01-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-05 | 2019-01-08 | N |
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