A list of the most recent deficiencies for Meadow Creek 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-20 | 2024-03-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-20 | 2024-03-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-20 | 2024-03-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-27 | 2024-01-18 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-12-27 | 2024-01-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-29 | 2023-10-23 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-09-14 | 2023-10-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-21 | 2023-10-06 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-08-31 | 2023-09-26 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-07-26 | 2023-08-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-03 | 2023-07-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-28 | 2023-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-28 | 2023-07-20 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-04-27 | 2023-05-26 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-04-27 | 2023-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-10 | 2023-04-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-23 | 2023-04-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-23 | 2023-04-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-23 | 2023-04-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-14 | 2023-02-02 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-22 | 2022-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-22 | 2022-10-21 | Y |
| Keep all essential equipment working safely. | Health | 2022-09-22 | 2022-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-15 | 2022-10-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-15 | 2022-10-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-15 | 2022-10-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-15 | 2021-11-18 | Y |
| Provide appropriate foot care. | Health | 2021-09-15 | 2021-11-18 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-04-19 | 2021-05-27 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-04-19 | 2021-05-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-19 | 2021-05-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-19 | 2021-05-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-19 | 2021-05-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-19 | 2021-05-27 | 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 | 2021-04-19 | 2021-05-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-19 | 2021-05-27 | 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 | 2021-04-19 | 2021-05-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-19 | 2021-05-27 | N |
| Keep all essential equipment working safely. | Health | 2021-04-19 | 2021-05-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-16 | 2021-05-20 | 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 | 2019-08-20 | 2019-09-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-20 | 2019-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-20 | 2019-09-18 | 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 | 2019-08-20 | 2019-09-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-08-20 | 2019-09-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-20 | 2019-09-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-20 | 2019-09-18 | 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 | 2019-08-20 | 2019-09-18 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-08-20 | 2019-09-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-20 | 2019-09-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-16 | 2018-10-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-16 | 2018-10-17 | 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 | 2018-08-14 | 2018-09-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-08-14 | 2018-09-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-14 | 2018-09-15 | 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 | 2018-08-14 | 2018-09-15 | 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 | 2018-08-14 | 2018-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-14 | 2018-09-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-14 | 2018-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-14 | 2018-09-15 | N |
