MEADOWVIEW HEALTHCARE AND REHAB

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Provide training in compliance and ethics.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Administration Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Have policies on smoking.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 11, 2025

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

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.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 12, 2023

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 7, 2022

Report COVID19 data to residents and families.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 7, 2022

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 12, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2023

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 20, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 7, 2022

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 7, 2022