Deficiency Records for The Meadows Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for The Meadows Health and Rehabilitation 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? |
|---|---|---|---|---|
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-11-30 | 2024-01-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-01 | 2023-12-29 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-12-01 | 2023-12-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-01 | 2023-12-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-01 | 2023-12-29 | 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 | 2023-12-01 | 2023-12-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-01 | 2023-12-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-01 | 2023-12-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-01 | 2023-12-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-01 | 2023-12-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-01 | 2023-12-29 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-01 | 2023-12-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2023-12-29 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-11-30 | 2023-12-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-11-30 | 2023-12-20 | 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 | 2023-11-30 | 2023-12-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-30 | 2023-12-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-30 | 2023-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-30 | 2023-12-20 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-04-20 | 2023-05-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| 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 | 2022-09-29 | 2022-11-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-09-29 | 2022-11-04 | 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 | 2022-09-29 | 2022-11-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-29 | 2022-11-04 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-09-29 | 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 | 2022-09-29 | 2022-09-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-10 | 2022-04-09 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-09-22 | 2021-10-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-02 | 2021-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-02 | 2021-07-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-02 | 2021-07-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-02 | 2021-07-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-02 | 2021-07-03 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-01 | 2021-07-02 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-07-01 | 2021-07-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-01 | 2021-07-02 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-07-01 | 2021-07-02 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-07-01 | 2021-07-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-01 | 2021-07-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-01 | 2021-07-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-01 | 2021-07-02 | N |
