A list of the most recent deficiencies for Meadowbrook at Appleton. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-10-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-29 | 2023-04-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-29 | 2023-04-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-29 | 2023-04-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-29 | 2023-04-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-29 | 2023-04-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-29 | 2023-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-29 | 2023-04-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-29 | 2023-04-27 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-03-29 | 2023-04-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-09 | 2023-02-09 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-09 | 2023-02-09 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-27 | 2022-10-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-27 | 2022-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-27 | 2022-10-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-27 | 2022-10-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-27 | 2022-10-20 | Y |
| 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 | 2022-09-27 | 2022-10-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-04 | 2022-08-24 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-04 | 2022-08-24 | 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 | 2022-04-18 | 2022-05-17 | N |
| 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 | 2022-04-18 | 2022-05-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-18 | 2022-05-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-18 | 2022-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-18 | 2022-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-18 | 2022-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-18 | 2022-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-18 | 2022-05-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-18 | 2022-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-18 | 2022-05-17 | 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 | 2022-04-18 | 2022-05-17 | 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 | 2022-04-18 | 2022-05-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-18 | 2022-05-17 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-04-18 | 2022-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-18 | 2022-05-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-18 | 2022-05-17 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-04-18 | 2022-05-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-18 | 2022-05-17 | Y |
| 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 | 2022-04-18 | 2022-05-17 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-13 | 2022-05-17 | N |
| Develop a communication plan. | Fire Safety | 2022-04-13 | 2022-05-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-13 | 2022-05-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-13 | 2022-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-03 | 2022-01-21 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-10-18 | 2021-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-18 | 2021-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-07 | 2021-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-10-29 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-07 | 2021-10-06 | Y |
| 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 | 2021-09-07 | 2021-10-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-07 | 2021-10-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-07 | 2021-10-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-07 | 2021-10-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-07 | 2021-10-06 | 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 | 2021-09-07 | 2021-10-06 | Y |
| Post nurse staffing information every day. | Health | 2021-09-07 | 2021-10-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-07 | 2021-10-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-05 | 2021-10-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-05 | 2021-10-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-05 | 2021-10-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-05 | 2021-10-06 | Y |
| Post nurse staffing information every day. | Health | 2021-08-05 | 2021-10-06 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-15 | 2021-10-06 | Y |
| 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 | 2021-07-15 | 2021-10-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-15 | 2021-10-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-10-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-15 | 2021-10-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-08-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-05 | 2021-08-27 | Y |
| 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 | 2021-08-05 | 2021-08-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-05 | 2021-08-27 | 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 | 2021-08-05 | 2021-08-27 | Y |
| 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 | 2021-08-05 | 2021-08-27 | Y |
| 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 | 2021-08-05 | 2021-08-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-05 | 2021-08-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-08-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-15 | 2021-08-13 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-07-15 | 2021-08-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-15 | 2021-08-13 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-07-15 | 2021-08-13 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-15 | 2021-08-13 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-07-15 | 2021-08-13 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-07-15 | 2021-08-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-05 | 2021-06-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-05 | 2021-06-02 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-05-05 | 2021-06-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-05 | 2021-06-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-05 | 2021-06-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-21 | 2021-05-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-21 | 2021-05-21 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-04-21 | 2021-05-21 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-04-21 | 2021-05-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-21 | 2021-05-21 | 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 | 2021-04-21 | 2021-05-21 | N |
| Post nurse staffing information every day. | Health | 2021-04-21 | 2021-05-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-21 | 2021-05-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-21 | 2021-05-21 | 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 | 2021-04-21 | 2021-05-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-21 | 2021-05-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-04-21 | 2021-05-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-21 | 2021-05-21 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-21 | 2021-05-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-21 | 2021-05-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-21 | 2021-05-21 | 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 | 2021-04-21 | 2021-05-21 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-19 | 2021-05-21 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-04-19 | 2021-05-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-19 | 2021-05-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-19 | 2021-05-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-19 | 2021-05-21 | N |
