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Deficiency Records for Meadowbrook at Appleton
A list of the most recent deficiencies for Meadowbrook at Appleton. 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 at Appleton. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-12 | 2024-07-05 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-08 | 2024-06-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-08 | 2024-06-06 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-05-08 | 2024-06-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-08 | 2024-06-06 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-05-08 | 2024-06-06 | 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 | 2024-05-08 | 2024-06-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-08 | 2024-06-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-08 | 2024-06-03 | 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 | 2024-05-08 | 2024-06-03 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-05-08 | 2024-06-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-08 | 2024-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-08 | 2024-06-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-08 | 2024-06-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-08 | 2024-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-05-08 | 2024-06-03 | 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 | 2024-05-08 | 2024-06-03 | 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 | 2024-05-08 | 2024-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-08 | 2024-06-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-08 | 2024-06-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-08 | 2024-06-03 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-08 | 2024-06-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-08 | 2024-05-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-08 | 2024-05-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-08 | 2024-05-30 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-05-08 | 2024-05-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-05-08 | 2024-05-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-08 | 2024-05-28 | 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 | 2024-05-08 | 2024-05-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-08 | 2024-05-09 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-04-02 | 2024-04-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-11 | 2024-04-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-10-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-29 | 2023-04-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-29 | 2023-04-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-29 | 2023-04-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-29 | 2023-04-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-29 | 2023-04-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-29 | 2023-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-29 | 2023-04-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-29 | 2023-04-27 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-03-29 | 2023-04-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-09 | 2023-02-09 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-09 | 2023-02-09 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-27 | 2022-10-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-27 | 2022-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-27 | 2022-10-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-27 | 2022-10-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-27 | 2022-10-20 | 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 | 2022-09-27 | 2022-10-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-04 | 2022-08-24 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-04 | 2022-08-24 | 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 | 2022-04-18 | 2022-05-17 | 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 | 2022-04-18 | 2022-05-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-18 | 2022-05-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-18 | 2022-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-18 | 2022-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-18 | 2022-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-18 | 2022-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-18 | 2022-05-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-18 | 2022-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-18 | 2022-05-17 | 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 | 2022-04-18 | 2022-05-17 | 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 | 2022-04-18 | 2022-05-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-18 | 2022-05-17 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-04-18 | 2022-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-18 | 2022-05-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-18 | 2022-05-17 | 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 | 2022-04-18 | 2022-05-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-18 | 2022-05-17 | Y |
| 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 | 2022-04-18 | 2022-05-17 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-13 | 2022-05-17 | N |
| Develop a communication plan. | Fire Safety | 2022-04-13 | 2022-05-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-13 | 2022-05-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-13 | 2022-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-03 | 2022-01-21 | Y |
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