A list of the most recent deficiencies for Meadowbrook Nursing 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? |
|---|---|---|---|---|
| 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 | 2023-07-31 | 2023-08-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-31 | 2023-08-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-07-31 | 2023-08-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-31 | 2023-08-18 | 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 | 2023-07-31 | 2023-08-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-31 | 2023-08-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-07-31 | 2023-08-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-31 | 2023-08-18 | 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 | 2023-07-31 | 2023-08-18 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-07-31 | 2023-08-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-31 | 2023-08-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-31 | 2023-08-18 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-07-31 | 2023-08-18 | 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 | 2020-02-13 | 2020-03-17 | 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 | 2020-02-13 | 2020-03-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-13 | 2020-03-13 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-02-13 | 2020-03-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-02-12 | 2020-03-12 | 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 | 2020-02-13 | 2020-02-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-12 | 2020-02-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-06 | 2018-12-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-06 | 2018-12-11 | N |
| Respond appropriately to all alleged violations. | Health | 2018-11-06 | 2018-12-11 | 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 | 2018-11-06 | 2018-12-11 | 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 | 2018-11-06 | 2018-12-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-06 | 2018-12-11 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-11-06 | 2018-12-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-11-06 | 2018-12-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-09-06 | 2017-11-01 | N |
