A list of the most recent deficiencies for Meadowbrook Rehabilitation Hospital. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2024-02-07 | 2024-03-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-07 | 2024-03-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-07 | 2024-03-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-07 | 2024-03-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-07 | 2024-03-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-07 | 2024-03-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-07 | 2024-03-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-25 | 2024-03-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-25 | 2024-03-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-25 | 2024-03-05 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-25 | 2024-03-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-25 | 2024-03-05 | 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 | 2024-01-25 | 2024-03-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-25 | 2024-03-05 | 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 | 2024-01-25 | 2024-03-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-25 | 2024-03-05 | 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 | 2024-01-25 | 2024-03-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-03-05 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-25 | 2024-03-05 | 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 | 2024-01-25 | 2024-03-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-01-25 | 2024-03-05 | N |
| Post nurse staffing information every day. | Health | 2024-01-25 | 2024-03-05 | 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 | 2024-01-25 | 2024-03-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-25 | 2024-03-05 | 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 | 2024-01-25 | 2024-03-05 | 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 | 2024-01-25 | 2024-03-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-25 | 2024-03-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-25 | 2024-03-05 | N |
| Keep all essential equipment working safely. | Health | 2024-01-25 | 2024-03-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-01 | 2023-03-28 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-01-18 | 2023-01-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-27 | 2023-01-16 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-27 | 2023-01-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-08 | 2023-01-03 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-12-08 | 2023-01-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-12-08 | 2023-01-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-25 | 2022-08-22 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-06 | 2022-06-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-16 | 2022-04-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-16 | 2022-04-21 | 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 | 2022-03-16 | 2022-04-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-16 | 2022-04-21 | Y |
| 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 | 2022-03-16 | 2022-04-21 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-16 | 2022-04-21 | Y |
| 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 | 2022-03-16 | 2022-04-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-16 | 2022-04-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-16 | 2022-04-21 | Y |
| 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 | 2022-04-06 | 2022-04-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-06 | 2022-04-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-06 | 2022-04-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-06 | 2022-04-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-06 | 2022-04-18 | 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 | 2021-02-17 | 2021-03-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-02-17 | 2021-03-18 | 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 | 2021-02-17 | 2021-03-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-02-17 | 2021-03-18 | 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 | 2021-02-17 | 2021-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-17 | 2021-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-17 | 2021-03-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| Use approved construction type or materials. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-03-17 | 2020-05-07 | 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 | 2020-03-17 | 2020-05-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-17 | 2020-05-07 | N |
