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Deficiency Records for Meadowbrook Acres
A list of the most recent deficiencies for Meadowbrook Acres. 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 Meadowbrook Acres. 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 a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-06 | 2024-06-14 | Y |
| 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 | 2023-08-29 | 2023-09-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-29 | 2023-09-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-29 | 2023-09-13 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-19 | 2023-05-26 | 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 | 2023-04-19 | 2023-05-26 | 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 | 2023-04-19 | 2023-05-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-19 | 2023-05-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-19 | 2023-05-26 | 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 | 2023-04-19 | 2023-05-26 | 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 | 2023-04-19 | 2023-05-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-04-19 | 2023-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-19 | 2023-05-26 | N |
| Dispose of garbage and refuse properly. | Health | 2023-04-19 | 2023-05-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-19 | 2023-05-26 | N |
| Keep all essential equipment working safely. | Health | 2023-04-19 | 2023-05-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-19 | 2023-05-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-19 | 2023-05-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-01 | 2022-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-01 | 2022-05-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-01 | 2022-05-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-01 | 2022-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-01 | 2022-05-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-04-01 | 2022-05-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-17 | 2022-04-26 | 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 | 2022-03-17 | 2022-04-26 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-17 | 2022-04-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-17 | 2022-04-26 | 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 | 2022-03-17 | 2022-04-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-17 | 2022-04-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-17 | 2022-04-26 | 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 | 2022-03-17 | 2022-04-26 | N |
| 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 | 2022-03-17 | 2022-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-17 | 2022-04-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-17 | 2022-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-04-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-17 | 2022-04-26 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-03-17 | 2022-04-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-17 | 2022-04-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-17 | 2022-04-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-01-20 | 2021-03-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-01-20 | 2021-03-08 | 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 | 2021-01-20 | 2021-03-08 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-01-20 | 2021-03-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-01-20 | 2021-03-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-01-20 | 2021-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-01-20 | 2021-03-08 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-01-20 | 2021-03-08 | 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 | 2021-01-20 | 2021-03-08 | 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 | 2021-01-20 | 2021-03-08 | 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 | 2021-01-20 | 2021-03-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-01-20 | 2021-03-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-01-20 | 2021-03-08 | 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 | 2021-01-20 | 2021-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-01-20 | 2021-03-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-01-20 | 2021-03-08 | N |
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