Deficiency Records for Meadowbrook Village Christian Retirement Community
Updated as of March 01, 2024
A list of the most recent deficiencies for Meadowbrook Village Christian Retirement Community. 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? |
|---|---|---|---|---|
| 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 | 2023-11-30 | 2024-01-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-30 | 2024-01-04 | 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 | 2023-11-30 | 2024-01-04 | 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 | 2023-11-30 | 2024-01-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-30 | 2024-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2024-01-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-12-06 | 2023-12-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-09-15 | 2022-10-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-15 | 2022-10-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-09-19 | 2022-10-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-12-03 | 2019-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-03 | 2019-12-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-03 | 2019-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-03 | 2019-12-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-15 | 2019-11-27 | N |
