A list of the most recent deficiencies for Meadow Lane Restorative Care 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? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-03-02 | 2023-04-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-02 | 2023-04-14 | Y |
| 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 | 2022-12-14 | 2023-01-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-14 | 2023-01-20 | 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 | 2022-12-14 | 2023-01-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-14 | 2023-01-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-14 | 2023-01-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-14 | 2023-01-20 | N |
| Post nurse staffing information every day. | Health | 2022-12-14 | 2023-01-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-12-14 | 2023-01-20 | 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 | 2022-12-14 | 2023-01-20 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-13 | 2023-01-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-04 | 2022-06-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-04 | 2022-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-04 | 2022-06-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-07 | 2022-04-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-27 | 2021-10-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-27 | 2021-10-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-27 | 2021-10-11 | 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 | 2021-08-27 | 2021-10-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-27 | 2021-10-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-27 | 2021-10-11 | 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 | 2021-08-27 | 2021-10-11 | 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 | 2021-08-27 | 2021-10-11 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-08-27 | 2021-10-11 | 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 | 2021-08-27 | 2021-10-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-27 | 2021-10-11 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-08-27 | 2021-10-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-08-27 | 2021-10-11 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-27 | 2021-10-11 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-27 | 2021-10-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-27 | 2021-10-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-27 | 2021-10-11 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-08-27 | 2021-10-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-08-27 | 2021-10-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-24 | 2021-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-10-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-20 | 2021-06-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-20 | 2021-06-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-27 | 2021-06-04 | Y |
| 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 | 2021-04-20 | 2021-05-28 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-15 | 2019-12-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-18 | 2019-11-29 | 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 | 2019-10-18 | 2019-11-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-18 | 2019-11-29 | 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 | 2019-10-18 | 2019-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-18 | 2019-11-29 | 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 | 2019-10-18 | 2019-11-29 | 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 | 2019-10-18 | 2019-11-29 | N |
| Post nurse staffing information every day. | Health | 2019-10-18 | 2019-11-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-18 | 2019-11-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-15 | 2019-11-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-15 | 2019-11-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-15 | 2019-11-05 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-10-15 | 2019-11-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-15 | 2019-10-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-15 | 2019-10-16 | N |
