Deficiency Records for Meadowbrook Behavioral Health Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Meadowbrook Behavioral Health Center. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-01-12 | 2024-02-10 | 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 | 2024-01-12 | 2024-02-10 | 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 | 2024-01-12 | 2024-02-10 | 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 | 2024-01-12 | 2024-02-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-12 | 2024-02-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-12 | 2024-02-10 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-01-12 | 2024-02-10 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-01-12 | 2024-02-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-12 | 2024-02-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-11 | 2024-02-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-04 | 2023-10-16 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-04 | 2023-10-16 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-28 | 2023-03-28 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-02-24 | 2023-03-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-24 | 2023-03-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-24 | 2023-03-20 | 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 | 2023-02-24 | 2023-03-20 | 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 | 2023-02-24 | 2023-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-24 | 2023-03-20 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-02-24 | 2023-03-20 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-02-24 | 2023-03-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-28 | 2023-03-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-02-28 | 2023-03-20 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-02-28 | 2023-03-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-28 | 2023-03-20 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-12-08 | 2022-12-30 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-12-08 | 2022-12-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2022-12-30 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-12-08 | 2022-12-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-20 | 2021-03-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-15 | 2019-12-13 | N |
| 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 | 2019-11-15 | 2019-12-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-15 | 2019-12-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-15 | 2019-12-13 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-11-15 | 2019-12-13 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-11-15 | 2019-12-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-11-15 | 2019-12-13 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-11-13 | 2019-12-06 | 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 | 2019-11-13 | 2019-12-06 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-11-13 | 2019-12-06 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-11-13 | 2019-12-06 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-11-13 | 2019-12-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-13 | 2019-12-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-13 | 2019-12-06 | N |
