A list of the most recent deficiencies for Meadowbrook Post Acute. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-31 | 2024-02-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-31 | 2024-02-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-31 | 2024-02-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-02-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-24 | 2023-11-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-25 | 2023-10-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-25 | 2023-10-24 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-05-15 | 2023-06-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-15 | 2023-06-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-15 | 2023-01-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-21 | 2022-12-10 | 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 | 2022-11-21 | 2022-12-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-21 | 2022-12-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-21 | 2022-11-29 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-11-21 | 2022-11-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-29 | 2022-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-25 | 2022-09-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-25 | 2022-09-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-25 | 2022-09-08 | 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 | 2022-06-23 | 2022-07-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-17 | 2022-06-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-02 | 2022-06-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-02 | 2022-06-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-02 | 2022-06-07 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-04-07 | 2022-04-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-02 | 2022-03-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-01 | 2022-03-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-01 | 2022-03-15 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-11-09 | 2021-12-23 | 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 | 2021-11-09 | 2021-12-23 | 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 | 2021-11-09 | 2021-12-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-09 | 2021-12-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-09 | 2021-12-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-09 | 2021-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-09 | 2021-12-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-09 | 2021-12-23 | 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 | 2021-11-09 | 2021-12-23 | 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 | 2021-11-09 | 2021-12-23 | 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 | 2021-11-09 | 2021-12-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-11-09 | 2021-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-09 | 2021-12-23 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-09 | 2021-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-03 | 2021-12-09 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-09 | 2021-11-29 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-06-14 | 2021-06-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-23 | 2021-04-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-06 | 2019-07-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-06-06 | 2019-07-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-06 | 2019-07-01 | N |
| Develop a communication plan. | Fire Safety | 2019-06-06 | 2019-07-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-06 | 2019-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-06 | 2019-07-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-06 | 2019-07-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-06 | 2019-07-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-06 | 2019-07-01 | 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 | 2019-04-25 | 2019-05-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-04-25 | 2019-05-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-04-25 | 2019-05-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-25 | 2019-05-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-25 | 2019-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-25 | 2019-05-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-25 | 2019-05-31 | 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 | 2019-04-25 | 2019-05-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-25 | 2019-05-31 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-04-25 | 2019-05-31 | 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 | 2019-04-25 | 2019-05-31 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-04-25 | 2019-05-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-04-25 | 2019-05-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-25 | 2019-05-31 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-04-25 | 2019-05-31 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-04-25 | 2019-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-25 | 2019-05-31 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-04-25 | 2019-05-31 | N |
| Keep all essential equipment working safely. | Health | 2019-04-25 | 2019-05-31 | N |
| Have policies on smoking. | Health | 2019-04-25 | 2019-05-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-11 | 2018-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-11 | 2018-10-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-09-11 | 2018-10-04 | N |
| Ensure that gas containers are correctly designed and tested, and in locations that are labeled. | Fire Safety | 2018-09-11 | 2018-10-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-01 | 2018-06-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-01 | 2018-06-28 | 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 | 2018-06-01 | 2018-06-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-01 | 2018-06-28 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-06-01 | 2018-06-28 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-06-01 | 2018-06-28 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-06-01 | 2018-06-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-06-01 | 2018-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-01 | 2018-06-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-01 | 2018-06-28 | N |
