Deficiency Records for Meadow View Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Meadow View Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-08-14 | 2023-08-14 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-14 | 2023-03-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-14 | 2023-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-20 | 2023-02-27 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-02-08 | 2023-02-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-08 | 2023-02-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-06 | 2023-02-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-23 | 2023-02-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-20 | 2022-12-27 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-20 | 2022-12-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-20 | 2022-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-20 | 2022-12-27 | 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 | 2022-09-20 | 2022-12-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-23 | 2022-12-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-23 | 2022-12-27 | 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 | 2022-11-23 | 2022-12-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-20 | 2022-11-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-20 | 2022-11-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-20 | 2022-11-04 | N |
| 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 | 2022-09-20 | 2022-11-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-20 | 2022-11-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-20 | 2022-11-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-20 | 2022-11-04 | 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 | 2022-09-20 | 2022-11-04 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-20 | 2022-11-04 | N |
| Provide activities to meet all resident's needs. | Health | 2022-09-20 | 2022-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-20 | 2022-11-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-20 | 2022-11-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-20 | 2022-11-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-20 | 2022-11-04 | 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 | 2022-09-20 | 2022-11-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-20 | 2022-11-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-20 | 2022-11-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-20 | 2022-11-04 | 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 | 2022-09-20 | 2022-11-04 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-09-20 | 2022-11-04 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-20 | 2022-11-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-11 | 2019-11-25 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-10-11 | 2019-11-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-11 | 2019-11-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-11 | 2019-11-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-11 | 2019-11-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-11 | 2019-11-25 | 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 | 2019-10-11 | 2019-11-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-11 | 2019-11-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-03 | 2018-11-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-10-03 | 2018-11-09 | 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 | 2018-10-03 | 2018-11-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-03 | 2018-11-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-03 | 2018-11-09 | 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 | 2018-10-03 | 2018-11-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-03 | 2018-11-09 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-10-03 | 2018-11-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-03 | 2018-11-09 | N |
| Dispose of garbage and refuse properly. | Health | 2018-10-03 | 2018-11-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-03 | 2018-11-09 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2018-10-03 | 2018-11-09 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-10-03 | 2018-11-09 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Use approved construction type or materials. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-03 | 2018-11-09 | N |
