CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for The Haven of Meadowbrook
A list of the most recent deficiencies for The Haven of Meadowbrook. 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 The Haven of Meadowbrook. 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? |
|---|---|---|---|---|
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-04-24 | 2025-05-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-04-24 | 2025-05-01 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-17 | 2025-04-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-04-24 | 2025-04-25 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2025-03-11 | 2025-04-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-03-17 | 2025-04-02 | 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 | 2025-03-11 | 2025-03-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-03-11 | 2025-03-27 | 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 | 2025-03-11 | 2025-03-27 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2025-03-11 | 2025-03-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-03-11 | 2025-03-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2025-03-11 | 2025-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-11 | 2025-03-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-03-11 | 2025-03-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-03-17 | 2025-03-27 | 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 | 2025-03-17 | 2025-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-03-17 | 2025-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-03-11 | 2025-03-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-11 | 2025-03-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-03-11 | 2025-03-27 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2025-03-11 | 2025-03-27 | 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 | 2025-03-11 | 2025-03-27 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2025-03-11 | 2025-03-27 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2025-03-11 | 2025-03-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-03-11 | 2025-03-27 | 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 | 2025-03-11 | 2025-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-15 | 2024-09-05 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-15 | 2024-09-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-15 | 2024-09-05 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-08-15 | 2024-09-05 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-08-15 | 2024-09-05 | 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 | 2024-08-15 | 2024-09-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-15 | 2024-09-05 | 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 | 2024-08-15 | 2024-09-05 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-07-29 | 2024-08-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-29 | 2024-08-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-29 | 2024-08-07 | Y |
| 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 | 2024-07-29 | 2024-08-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-19 | 2024-08-02 | Y |
| 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 | 2024-07-19 | 2024-08-02 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-07-19 | 2024-08-02 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-07 | 2024-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-07 | 2024-07-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-07 | 2024-07-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-07 | 2024-07-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-31 | 2024-06-13 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-07 | 2024-06-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-07 | 2024-06-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-07 | 2024-06-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-07 | 2024-06-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-07 | 2024-06-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-10 | 2024-06-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-10 | 2024-06-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-10 | 2024-06-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-10 | 2024-06-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-05-10 | 2024-06-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-05-10 | 2024-06-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-05-10 | 2024-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-10 | 2024-06-05 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-05-10 | 2024-06-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-10 | 2024-06-05 | 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 | 2024-05-10 | 2024-06-05 | 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 | 2024-05-10 | 2024-06-05 | 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 | 2024-05-10 | 2024-06-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-10 | 2024-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-10 | 2024-06-05 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-05-10 | 2024-06-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-07 | 2024-06-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-07 | 2024-06-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-07 | 2024-06-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-07 | 2024-06-02 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| Establish methods for sharing information. | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-05-07 | 2024-05-31 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-03-14 | 2024-03-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-15 | 2024-03-08 | 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 | 2024-02-15 | 2024-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-15 | 2024-03-08 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-20 | 2023-10-07 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-09-20 | 2023-10-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-10-07 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-08-05 | 2023-08-28 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-08-05 | 2023-08-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-29 | 2023-07-13 | Y |
| 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 | 2023-04-26 | 2023-07-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-26 | 2023-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-26 | 2023-07-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-07-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-26 | 2023-07-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-26 | 2023-06-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-26 | 2023-06-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-26 | 2023-06-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-26 | 2023-06-08 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-26 | 2023-06-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-06-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-10 | 2023-06-08 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-10 | 2023-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-10 | 2023-06-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-10 | 2023-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-06-08 | 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 | 2023-05-10 | 2023-06-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-10 | 2023-06-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-26 | 2023-06-08 | 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 | 2023-04-26 | 2023-06-08 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-26 | 2023-06-08 | 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 | 2023-04-26 | 2023-06-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-26 | 2023-06-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-06-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-04-26 | 2023-06-08 | 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 | 2023-04-26 | 2023-06-08 | 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 | 2023-04-13 | 2023-06-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-13 | 2023-06-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-13 | 2023-06-08 | Y |
| Post nurse staffing information every day. | Health | 2023-05-10 | 2023-06-08 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-25 | 2023-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-06-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Develop a communication plan. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-25 | 2023-05-26 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-16 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-31 | 2023-02-14 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-01-31 | 2023-02-14 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-01-31 | 2023-02-14 | 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 | 2023-01-31 | 2023-02-10 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-01-31 | 2023-02-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-07 | 2023-02-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-07 | 2023-02-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-07 | 2023-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-07 | 2023-01-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-09 | 2022-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-11 | 2022-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-30 | 2022-10-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-10 | 2022-10-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-22 | 2022-10-25 | 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 | 2022-08-10 | 2022-10-04 | 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 | 2022-07-22 | 2022-10-04 | Y |
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