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Deficiency Records for Meadowbrook at Oconto Falls
A list of the most recent deficiencies for Meadowbrook at Oconto Falls. 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 Oconto Falls. 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 generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-29 | 2024-07-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-04-29 | 2024-06-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-21 | 2024-06-17 | Y |
| 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 | 2024-05-21 | 2024-06-17 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-04-30 | 2024-06-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-30 | 2024-06-03 | N |
| 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 | 2024-04-30 | 2024-06-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-30 | 2024-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-04-30 | 2024-06-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-30 | 2024-06-03 | 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 | 2024-04-30 | 2024-06-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-30 | 2024-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-30 | 2024-06-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-30 | 2024-06-03 | N |
| Keep all essential equipment working safely. | Health | 2024-04-30 | 2024-06-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-29 | 2024-05-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-29 | 2024-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-29 | 2024-05-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-04-29 | 2024-05-01 | 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 | 2024-04-29 | 2024-05-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-04-29 | 2024-05-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-04-29 | 2024-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-29 | 2024-05-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-29 | 2024-05-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-29 | 2024-05-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-04-29 | 2024-05-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-02 | 2024-01-23 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-03-16 | 2023-04-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-16 | 2023-04-05 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-16 | 2023-04-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-14 | 2023-04-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-16 | 2023-03-31 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-03-16 | 2023-03-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-16 | 2023-03-20 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-16 | 2023-03-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-16 | 2023-03-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-16 | 2023-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-16 | 2023-03-17 | 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 | 2023-03-16 | 2023-03-17 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-14 | 2023-03-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-14 | 2023-03-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-01 | 2022-12-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-01 | 2022-12-15 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-12-01 | 2022-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-25 | 2022-10-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-13 | 2022-06-30 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-06-13 | 2022-06-14 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-10 | 2022-03-22 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-09 | 2022-03-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-09 | 2022-03-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-09 | 2022-03-15 | 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 | 2022-03-09 | 2022-03-15 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-09 | 2022-03-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-09 | 2022-03-14 | 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 | 2022-03-09 | 2022-03-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-09 | 2022-03-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-10 | 2022-03-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-10 | 2022-03-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-09 | 2022-03-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-10 | 2022-03-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-10 | 2022-03-11 | 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 | 2022-03-09 | 2022-03-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-09 | 2022-03-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-09 | 2022-03-10 | N |
| 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 | 2022-03-09 | 2022-03-10 | N |
| Post nurse staffing information every day. | Health | 2022-03-09 | 2022-03-10 | 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 | 2022-03-09 | 2022-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-09 | 2022-03-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-09 | 2022-03-10 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-09 | 2022-03-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-23 | 2022-02-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-23 | 2022-02-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-02-24 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-23 | 2022-02-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-04 | 2022-02-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-04 | 2022-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-04 | 2022-02-03 | Y |
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