Deficiency Records for Meadow Woods Nursing and Rehab Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Meadow Woods Nursing and Rehab 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-19 | 2024-01-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-19 | 2024-01-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-19 | 2024-01-09 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-09 | 2023-08-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-09 | 2023-08-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-10 | 2023-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-08-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-10 | 2023-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-08-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-10 | 2023-08-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-10 | 2023-08-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-10 | 2023-08-29 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-21 | 2022-08-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-21 | 2022-08-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-21 | 2022-08-11 | 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 | 2022-07-21 | 2022-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-21 | 2022-08-11 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-07-21 | 2022-08-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-21 | 2022-08-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-21 | 2022-08-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-21 | 2022-08-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-21 | 2022-08-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-21 | 2022-08-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-21 | 2022-08-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-28 | 2021-07-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-28 | 2021-07-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-28 | 2021-07-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-28 | 2021-07-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-28 | 2021-07-22 | 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 | 2021-06-28 | 2021-07-22 | 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 | 2021-06-28 | 2021-07-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-29 | 2021-06-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-04-29 | 2021-06-04 | Y |
| Provide appropriate foot care. | Health | 2021-04-29 | 2021-06-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-29 | 2021-06-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-29 | 2021-06-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-29 | 2021-06-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-29 | 2021-06-04 | 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 | 2021-04-29 | 2021-06-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-29 | 2021-06-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-29 | 2021-06-04 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-04-26 | 2021-06-04 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-04-26 | 2021-06-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-26 | 2021-06-04 | 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 | 2021-04-26 | 2021-06-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-26 | 2021-06-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-26 | 2021-06-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-26 | 2021-06-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-26 | 2021-06-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-26 | 2021-06-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-26 | 2021-06-04 | N |
