Inspection Reports for Meadowbrook Rehabilitation Hospital
427 W. MAIN STREET, KS, 66030-1183
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 21, 2016, found no deficiencies, confirming that previously cited issues had been corrected. Earlier inspections showed a pattern of deficiencies related mainly to resident care, including skin condition assessments, fall investigations, infection control, medication management, and environmental safety such as secure handrails. A substantiated complaint investigation in August 2015 identified immediate jeopardy due to inadequate bathing care and failure to prevent resident elopement, which was later abated through corrective actions. Fines, license suspensions, or other enforcement actions were not listed in the available reports. The facility’s inspection history indicates improvement over time, with more recent surveys showing resolution of prior deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
167% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
33 residents
Based on a July 2016 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Jul 21, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.25, 483.25(h), 483.25(n), 483.60(b),(d),(e), 483.65, and 483.70(h)(3) were corrected as of the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 13, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective July 21, 2016.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date of substantial compliance: Jul 21, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated findings |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 6
Jul 13, 2016
Visit Reason
The inspection was conducted as a Health Survey and Complaint Investigations #KS00090719 and #KS00100433 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to assess, monitor and treat skin conditions for a cognitively impaired resident, failure to investigate and evaluate causes of multiple falls for a resident, failure to provide current education on pneumococcal immunizations, failure to dispose of expired medications, failure to maintain sanitary infection control procedures, and failure to ensure handrails were firmly and securely affixed in corridors.
Complaint Details
The inspection included complaint investigations #KS00090719 and #KS00100433.
Severity Breakdown
SS=D: 3
SS=C: 1
SS=F: 1
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to assess, monitor and treat skin conditions for 1 of 3 residents reviewed for non-pressure related skin conditions. | SS=D |
| Failed to identify and evaluate causative factors of multiple falls for 1 of 3 residents reviewed for accidents. | SS=D |
| Failed to provide residents current education regarding benefits and potential side effects of pneumococcal vaccine for 5 of 5 residents reviewed. | SS=C |
| Failed to dispose of expired medications found in medication cart. | SS=D |
| Failed to follow sanitary infection control procedures including improper disinfectant contact time and uncovered linen transport. | SS=F |
| Failed to ensure handrails were firmly and securely affixed in corridor on 1 of 2 neighborhoods. | SS=E |
Report Facts
Census: 33
Sample size: 21
Expired medications: 5
Disinfectant contact time: 10
Disinfectant contact time observed: 3
Disinfectant contact time observed: 10
Loose handrails observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Direct care staff | Interviewed regarding skin assessments and lotion application for resident with skin condition |
| Staff P | Direct care staff | Interviewed regarding resident's skin picking behavior and documentation |
| Staff I | Licensed staff | Interviewed regarding resident's rash and treatment by dermatologist |
| Staff D | Administrative nursing staff | Confirmed failure to assess and monitor rash; commented on fall incident documentation |
| Staff Q | Direct care staff | Interviewed regarding fall interventions and care plan updates |
| Staff J | Direct care staff | Interviewed regarding resident's impulsive behavior and fall risk |
| Staff H | Licensed staff | Confirmed expired medications found in medication cart |
| Staff AA | Housekeeping staff | Observed cleaning with improper disinfectant contact time and interviewed about disinfectant use |
| Staff Z | Housekeeping staff | Interviewed regarding linen transport and disinfectant use |
| Staff Y | Maintenance staff | Confirmed loose handrails and repairs needed |
| Staff X | Administrative maintenance staff | Confirmed loose handrails on neighborhood 2 |
| Staff F | Administrative nursing staff | Interviewed regarding pneumococcal vaccine education materials |
Inspection Report
Plan of Correction
Deficiencies: 6
Jul 13, 2016
Visit Reason
This document is a Plan of Correction submitted by Meadowbrook Rehabilitation Hospital in response to deficiencies cited during a prior survey. It outlines corrective actions to address identified deficiencies and ensure compliance with regulations.
Findings
The facility identified multiple deficiencies including incomplete skin assessments, inadequate fall investigations, lack of current education on Pneumococcal vaccine, improper disposal of expired medications, unsafe sanitary conditions, and unsecured handrails. The Plan of Correction details education, audits, and monitoring measures to address these issues.
Severity Breakdown
C: 1
D: 3
E: 1
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to complete skin assessments upon admission/readmission, weekly, and after falls | D |
| Failure to ensure resident environment is free of accident hazards and inadequate fall investigations | D |
| Failure to provide current education regarding Pneumococcal vaccine benefits and side effects | C |
| Failure to properly dispose of expired medication | D |
| Failure to provide a safe, sanitary, and comfortable environment to prevent disease transmission | F |
| Failure to ensure handrails are firmly affixed and secured in corridors | E |
Report Facts
Audit date: Jul 13, 2016
Plan completion dates: Jul 21, 2016
Plan completion date: Aug 1, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon Scott | Administrator | Submitted the Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
Jan 31, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be at a 'D' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found at 'D' level with no harm but potential for more than minimal harm that is not immediate jeopardy. | D |
Report Facts
Effective date for denial of payments: May 1, 2016
Provider agreement termination date: Jul 31, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report and is the enforcement coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 2
Oct 6, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report shows that deficiencies previously cited under regulations 483.25(a)(3) and 483.25(h) were corrected as of 08/14/2015.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 2
Date of revisit: Oct 6, 2015
Date of correction completion: Aug 14, 2015
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 10, 2015
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety from July 23, 2015 through August 7, 2015 related to F323, CFR 483.25(h). Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed effective September 1, 2015.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F323, CFR 483.25(h) resulting in immediate jeopardy to resident health or safety | Immediate Jeopardy |
Report Facts
Denial of Payment Effective Date: Sep 1, 2015
Recommended Termination Date: Feb 10, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions regarding the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Aug 10, 2015
Visit Reason
The inspection was conducted as a partial extended complaint investigation related to allegations of inadequate bathing care and failure to prevent elopement of residents.
Findings
The facility failed to provide adequate bathing for a cognitively impaired resident requiring total assistance and failed to provide effective interventions to prevent elopement of a resident at risk, who was found walking alone 0.8 miles from the facility. The resident eloped twice without timely staff response, exposing him/her to immediate jeopardy.
Complaint Details
The complaint investigation found substantiated failures including inadequate bathing care and failure to prevent elopement of a resident who was found 0.8 miles from the facility after leaving unsupervised. Immediate jeopardy was identified and later abated.
Severity Breakdown
SS=D: 1
SS=J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide adequate bathing for a resident requiring extensive assistance. | SS=D |
| Failure to provide effective interventions to prevent elopement of a resident at risk, resulting in immediate jeopardy. | SS=J |
Report Facts
Census: 33
Distance resident eloped: 0.8
Speed limit: 45
Number of residents sampled: 4
Bath frequency: 2
BIMS score: 12
Elopement incidents: 2
Response time to door alarm: 30
Time resident was gone: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed staff H | Nurse | Found eloped resident and returned him/her to the facility; involved in elopement incident response |
| Licensed staff I | Nurse | Resident's nurse during elopement incident; involved in search and response |
| Administrative nursing staff E | Acknowledged lack of documentation for wanderguard checks | |
| Administrative nursing staff D | Provided information on bathing frequency and elopement incident | |
| Administrative staff B | Provided history of resident's elopement attempts | |
| Contract staff GG | Described staff response to wanderguard alarm | |
| Direct care staff O | Described bathing offer and refusal documentation | |
| Direct care staff P | Described elopement risk and staff monitoring | |
| Contract staff HH | Described resident's elopement risk and staff response time | |
| Administrative staff A | Stated facility lacked a wanderguard policy |
Inspection Report
Plan of Correction
Deficiencies: 2
Aug 10, 2015
Visit Reason
This Plan of Correction document responds to deficiencies identified during a complaint-related survey exiting on 08/10/2015 at Meadowbrook Rehabilitation Hospital, outlining corrective actions to achieve substantial compliance by 08/14/2015.
Findings
The facility had deficiencies related to activities of daily living care for dependent residents and ensuring a safe environment free of accident hazards, including supervision to prevent elopement. Corrective actions include updated bath schedules, staff re-education, elopement risk assessments, installation of security keypads and alarms, and ongoing monitoring and documentation.
Complaint Details
This plan of correction follows a complaint investigation survey exiting 08/10/2015. The facility asserts substantial compliance and outlines corrective actions to address the complaint deficiencies.
Severity Breakdown
D: 1
J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| ADL care provided for dependent residents was deficient, requiring updated bath schedules and care plans. | D |
| Failure to ensure resident environment was free of accident hazards and adequate supervision to prevent accidents and elopement. | J |
Report Facts
Deficiency completion date: Aug 14, 2015
Bath frequency: 2
Bath frequency: 3
Date of security keypad installation: Aug 5, 2015
Date of alarm installation: Aug 10, 2015
Date of staff re-education start: Aug 4, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon Scott | CEO/Administrator | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 9
Feb 28, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report documents that all previously cited deficiencies, identified by their regulation numbers and prefix codes, were corrected as of the revisit date.
Deficiencies (9)
| Description |
|---|
| Deficiency related to regulation 483.15(e)(2) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulations 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 9
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 30, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'E' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter regarding enforcement and plan of correction acceptance. |
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 10
Jan 30, 2015
Visit Reason
Health Licensure Resurvey conducted to assess compliance with state and federal regulations for Meadowbrook Rehabilitation Hospital LTCU.
Findings
The facility was found deficient in multiple areas including failure to notify residents prior to room changes, inaccurate and incomplete resident assessments, failure to update care plans timely, inadequate post-dialysis assessments, improper catheter care, fall prevention deficiencies, unsafe storage of hazardous chemicals, improper labeling of medications, failure to prevent infection transmission, and lack of physician participation in quality assurance meetings.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=C: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to notify resident or representative prior to room or roommate change. | SS=D |
| Failure to complete accurate Care Area Assessments (CAA) for residents with significant changes. | SS=D |
| Failure to complete accurate Minimum Data Set (MDS) assessments reflecting resident status and infections. | SS=D |
| Failure to update care plans timely to reflect changes in resident care needs. | SS=D |
| Failure to assess resident condition properly following dialysis treatments. | SS=D |
| Failure to provide appropriate catheter care and prevent catheter and tubing from touching the floor. | SS=D |
| Failure to maintain a safe environment free of accident hazards and provide adequate supervision to prevent falls. | SS=E |
| Failure to label and date opened medications and dressings in treatment carts. | SS=D |
| Failure to prevent exposure of a resident to MRSA and failure to prescreen resident before room transfer. | SS=E |
| Failure to ensure physician participation at least quarterly in Quality Assessment and Assurance meetings. | SS=C |
Report Facts
Residents present: 31
Residents sampled: 18
Fall risk score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse E | Interviewed regarding resident assessments and care plan updates | |
| licensed nursing staff J | Interviewed regarding dialysis assessments and catheter care | |
| administrative nursing staff D | Interviewed regarding room change notification, infection control, and QA&A meetings | |
| administrative nursing staff E | Interviewed regarding resident assessments and care plan updates | |
| direct care staff H, I, O, P, Q | Observed and interviewed regarding resident care and catheter management | |
| licensed social worker staff II | Interviewed regarding room change notification | |
| administrative nursing staff F | Interviewed regarding QA&A meeting attendance | |
| physical therapy staff JJ | Observed assisting resident transfer |
Inspection Report
Plan of Correction
Deficiencies: 10
Jan 30, 2015
Visit Reason
This document is a Plan of Correction submitted by Meadowbrook Rehabilitation Hospital in response to findings from a survey conducted on January 30, 2015. It outlines corrective actions and interventions to address specific deficiencies identified during the survey.
Findings
The Plan of Correction details multiple deficiencies related to residents' rights, comprehensive assessments, care planning, infection control, medication storage, fall prevention, and quality assurance processes. The facility commits to staff education, policy reviews, and ongoing monitoring to achieve substantial compliance by February 28, 2015.
Severity Breakdown
D: 6
E: 2
C: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Right to notice before room/roommate change | D |
| Comprehensive assessments accuracy | D |
| Assessment accuracy and coordination | D |
| Right to participate in planning care | D |
| Provide care/services for highest well-being | D |
| No catheter, prevent UTI, restore bladder | D |
| Free of accident hazards/supervision/devices | E |
| Drug records, labeling, and storage of drugs and biologicals | D |
| Infection control, prevent spread, linens | E |
| CQAA committee members, meetings, and plans | C |
Report Facts
Deficiencies cited: 10
Compliance completion date: Feb 28, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jon Scott | CEO/Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 5
Oct 24, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to document the dates when corrective actions were accomplished.
Findings
The report confirms that all previously cited deficiencies identified by their regulation numbers and prefix codes have been corrected as of the revisit date.
Deficiencies (5)
| Description |
|---|
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulations 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.65 |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Sep 25, 2014
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'D' level deficiencies indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Signed letter regarding survey results and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Sep 25, 2014
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers #79247 and #79372.
Findings
The facility failed to complete timely Care Area Assessments and comprehensive care plans for sampled residents, failed to provide adequate pain management, failed to administer and document scheduled IV antibiotics, and failed to maintain infection control practices related to PICC line dressing changes.
Complaint Details
The inspection was triggered by complaint investigations #79247 and #79372. The findings were substantiated as the facility failed in multiple regulatory requirements related to resident care and infection control.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to complete Care Area Assessments for 1 of 3 residents (#3). | SS=D |
| Failed to develop comprehensive care plans for 2 of 3 sampled residents (#1 and #3). | SS=D |
| Failed to provide adequate pain management for 1 of 3 sampled residents (#1). | SS=D |
| Failed to provide pharmaceutical services including administering and documenting IV antibiotics for 1 of 3 residents (#1). | SS=D |
| Failed to maintain infection control by not changing PICC line dressing as scheduled for 1 of 3 residents (#1). | SS=D |
Report Facts
Residents sampled: 3
Facility census: 37
Missed IV antibiotic doses: 18
Pain assessment missing shifts: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff D | Revealed facility followed Resident Assessment Instrument guidelines and confirmed failure to change PICC line dressing as scheduled. | |
| Administrative nursing staff E | Revealed failure to complete Care Area Assessments and comprehensive care plans for residents. | |
| Licensed nursing staff H | Observed flushing resident's PEG tube. | |
| Licensed nursing staff I | Revealed assessment and documentation of resident's pain level. |
Inspection Report
Plan of Correction
Deficiencies: 5
Sep 25, 2014
Visit Reason
This document is a Plan of Correction submitted by Meadowbrook Rehabilitation Hospital in response to deficiencies identified during a complaint-related survey exiting on 9/25/2014.
Findings
The plan addresses multiple deficiencies including comprehensive assessments, care plan development, pain management, pharmaceutical services, and infection control. The facility outlines corrective actions such as staff education, audits, monitoring, and quality assurance meetings to ensure substantial compliance by 10/24/2014.
Complaint Details
This Plan of Correction is in response to deficiencies identified during a complaint investigation survey exiting on 9/25/2014.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| F272 Comprehensive Assessments SS=D | D |
| F279 Develop Comprehensive Care Plans SS=D | D |
| F309 Provide Care/Services for Highest Well Being SS=D | D |
| F425 Pharmaceutical SVC-Accurate Procedures, RPH SS=D | D |
| F441 Infection Control, Prevent Spread, Linens SS=D | D |
Report Facts
Completion date for substantial compliance: Oct 24, 2014
Audit duration: 8
MDS Coordinator assistant hours: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for ongoing compliance, monitoring audits, and staff education |
| MDS/Care Plan Coordinator | MDS/Care Plan Coordinator | Completed Care Area Assessments and updated care plans; responsible for audits |
Inspection Report
Re-Inspection
Deficiencies: 2
Oct 31, 2013
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey conducted on 2013-10-07.
Findings
The report confirms that the previously identified deficiencies with ID prefixes S0600 and S1164 were corrected as of 2013-10-31.
Deficiencies (2)
| Description |
|---|
| Deficiency with regulation 28-39-158(a) corrected |
| Deficiency with regulation 26-40-303 (h)(1)(a)(i)(ii)(iii)(iv) corrected |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 31, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.10(c)(6), 483.15(e)(1), 483.15(h)(3), 483.20(d)-(j), and related provisions were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 2
Oct 7, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements following previous deficiencies.
Findings
The facility failed to have a Certified Dietary Manager for all on-site survey days and did not ensure the call light system functioned properly at the nurses' station annunciator panel for multiple days during the survey.
Severity Breakdown
SS=C: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to have a Certified Dietary Manager for 4 of 4 on-site survey days. | SS=C |
| Failure to ensure the call light system functioned properly at the nurses' station annunciator panel for 2 of 2 halls for 3 of 4 days during the survey. | SS=E |
Report Facts
Census: 34
Survey days: 4
Call light system failure days: 3
Halls affected: 2
Inspection Report
Follow-Up
Deficiencies: 3
Jul 24, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report shows that the previously cited deficiencies under regulations 483.13(c), 483.25(i), and 483.60(b),(d),(e) were corrected as of 07/09/2012.
Deficiencies (3)
| Description |
|---|
| Deficiency under regulation 483.13(c) |
| Deficiency under regulation 483.25(i) |
| Deficiency under regulation 483.60(b), (d), (e) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Jun 26, 2012
Visit Reason
This document is a Plan of Correction submitted by Meadowbrook Rehab in response to deficiencies cited during a prior inspection.
Findings
The plan addresses deficiencies related to abuse prevention policy updates, follow-up on dietary recommendations, and medication labeling and expiration monitoring. Corrective actions include policy updates, staff education, audits, and ongoing compliance monitoring.
Severity Breakdown
C: 1
G: 1
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Abuse Prevention Policy and Procedure was updated to reflect CMS requirements for timely reporting of suspected abuse. | C |
| Audit and follow-up on omitted dietary recommendations for discharged residents. | G |
| Audit and disposal of unlabeled and expired medications, with staff education on labeling and monitoring medication expiration. | D |
Report Facts
Date of audit for medication carts: Jun 26, 2012
Plan of correction completion date: Jul 9, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Markleneave | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 3
Jun 20, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with federal regulations related to abuse prevention, nutritional status maintenance, and medication management.
Findings
The facility failed to update its Abuse Prevention Policy to include timely reporting requirements, failed to maintain nutritional status for two residents with significant weight loss due to lack of implementation of dietary recommendations, and failed to properly label and date medications including insulin pens and multi-dose vials, retaining expired medications.
Severity Breakdown
SS=C: 1
SS=G: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide an Abuse Policy directing staff on the two time limits for reporting reasonable suspicion of a crime. | SS=C |
| Failure to maintain nutritional status for 2 residents with significant weight loss and failure to implement dietary recommendations. | SS=G |
| Failure to label insulin medications and multi-dose medication vials with an open date, and retention of expired medications. | SS=D |
Report Facts
Census: 31
Resident sample size: 18
Weight loss: 7.4
Weight loss: 5.4
Weight loss: 9.6
Weight loss: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff A | Acknowledged failure to update abuse prevention policy and failure to implement dietary recommendations. | |
| Dietary staff C | Provided information on RD recommendations and acknowledged resident weight loss. | |
| Administrative dietary staff D | Discussed weight loss and attempts to follow through with dietary recommendations. | |
| Licensed nursing staff B | Interviewed regarding insulin pen expiration and labeling. |
Document
Deficiencies: 0
H046101 2 POC TIRD11
Visit Reason
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Findings
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