A list of the most recent deficiencies for Meadow Manor. 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 and implement an infection prevention and control program. | Health | 2024-01-22 | 2024-02-02 | Y |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-11-28 | 2024-01-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-28 | 2024-01-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-28 | 2024-01-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-28 | 2024-01-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-28 | 2024-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | 2023-12-28 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-11-30 | 2023-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2023-12-07 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-30 | 2023-12-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-30 | 2023-12-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-30 | 2023-12-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-30 | 2023-12-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-12 | 2023-10-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-01 | 2022-11-23 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-07-15 | 2022-08-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-15 | 2022-08-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-07-15 | 2022-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-15 | 2022-08-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-15 | 2022-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-15 | 2022-08-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-07-15 | 2022-08-10 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-15 | 2022-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-15 | 2022-08-10 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-07-15 | 2022-08-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-05-06 | 2021-07-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-07 | 2021-06-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-07 | 2021-06-11 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-07 | 2021-06-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-07 | 2021-06-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-07 | 2021-06-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-07 | 2021-06-11 | 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 | 2021-05-07 | 2021-06-11 | 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 | 2021-05-07 | 2021-06-11 | 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 | 2021-05-07 | 2021-06-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-07 | 2021-06-11 | 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 | 2021-05-07 | 2021-06-11 | 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 | 2021-05-07 | 2021-06-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-05-07 | 2021-06-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-07 | 2021-06-11 | 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 | 2021-05-07 | 2021-06-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-07 | 2021-06-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-07 | 2021-06-11 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-07 | 2021-06-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-07 | 2021-06-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-07 | 2021-06-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-06 | 2021-06-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-06 | 2021-06-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-06 | 2021-06-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-06 | 2021-06-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-06 | 2021-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-06 | 2021-06-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-06 | 2021-06-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-07 | 2021-06-11 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-07 | 2021-06-11 | Y |
