Deficiency Records for Meadow Green Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Meadow Green Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-18 | 2023-03-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-11 | 2023-02-13 | 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 | 2023-01-11 | 2023-02-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-11 | 2023-02-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-11 | 2023-02-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-11 | 2023-02-13 | 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 | 2023-01-11 | 2023-02-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-11 | 2023-02-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-11 | 2023-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-13 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-22 | 2022-04-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-03-18 | 2021-04-08 | 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 | 2021-03-18 | 2021-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-18 | 2021-04-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-27 | 2019-11-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-08-27 | 2019-11-30 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-08-27 | 2019-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-27 | 2019-09-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-27 | 2019-09-27 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-08-27 | 2019-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-27 | 2019-09-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-27 | 2019-09-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-27 | 2019-09-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-08-27 | 2019-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-27 | 2019-09-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-06-12 | 2019-06-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-12 | 2019-06-28 | 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 | 2019-06-12 | 2019-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-12 | 2019-06-28 | N |
