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Deficiency Records for Meadow Brook Rehabilitation and Nursing
A list of the most recent deficiencies for Meadow Brook Rehabilitation and Nursing. 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 Brook Rehabilitation and Nursing. 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 | 2024-02-22 | 2024-04-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-22 | 2024-04-19 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-22 | 2024-04-19 | 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 | 2024-02-22 | 2024-04-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-22 | 2024-04-19 | 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 | 2024-02-22 | 2024-04-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-22 | 2024-04-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-22 | 2024-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-22 | 2024-04-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-22 | 2024-04-19 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-02-22 | 2024-04-19 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-22 | 2024-04-19 | 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 | 2024-02-22 | 2024-04-19 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-02-22 | 2024-04-19 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-22 | 2024-04-19 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-02-22 | 2024-04-19 | Y |
| Provide appropriate foot care. | Health | 2024-02-22 | 2024-04-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-22 | 2024-04-19 | 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 | 2024-02-22 | 2024-04-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-22 | 2024-04-19 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-02-22 | 2024-04-19 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-22 | 2024-04-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-22 | 2024-04-19 | 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 | 2024-02-22 | 2024-04-19 | 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 | 2024-02-22 | 2024-04-19 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-02-22 | 2024-04-19 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-02-22 | 2024-04-19 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-02-22 | 2024-04-19 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-22 | 2024-04-19 | 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 | 2024-02-22 | 2024-04-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-22 | 2024-04-19 | 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 | 2024-02-22 | 2024-04-19 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-02-22 | 2024-04-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-22 | 2024-04-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-22 | 2024-04-19 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-22 | 2024-04-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-22 | 2024-04-19 | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-02-22 | 2024-04-19 | Y |
| Keep all essential equipment working safely. | Health | 2024-02-22 | 2024-04-19 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-02-22 | 2024-04-19 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2024-02-22 | 2024-04-19 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-02-22 | 2024-04-19 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-02-12 | 2024-04-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-12 | 2024-03-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-12 | 2024-03-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-12 | 2024-03-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-12 | 2024-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-12 | 2024-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-12 | 2024-02-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-12 | 2024-02-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-11 | 2023-12-06 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-31 | 2022-07-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-25 | 2022-07-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-25 | 2022-07-15 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-25 | 2022-07-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-25 | 2022-07-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-31 | 2022-06-16 | 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 | 2022-05-31 | 2022-06-16 | N |
| 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 | 2019-12-18 | 2020-02-06 | 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 | 2019-12-18 | 2020-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-18 | 2020-02-06 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-12-18 | 2020-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-18 | 2020-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-18 | 2020-02-06 | N |
| Meet other general requirements. | Fire Safety | 2019-12-23 | 2020-01-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-23 | 2020-01-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-23 | 2020-01-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-23 | 2020-01-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-23 | 2020-01-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-23 | 2020-01-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-23 | 2020-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-23 | 2020-01-31 | N |
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