Meadow Brook Rehabilitation and Nursing

This section preserves official CMS inspection text matched to this facility from the current provider page source.

Inspection Report:
2025-11-20
This report is the official CMS Statement of Deficiencies (Form 2567) filed after the most recent health inspection.
Each
12
is a federal standard the facility failed to meet.
Read the full inspection report
Survey: 2025-11-20 | Tag F0584 | Resident Rights Deficiencies | Severity: E
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.
---
Survey: 2025-11-20 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
---
Survey: 2025-11-20 | Tag F0628 | Resident Rights Deficiencies | Severity: D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
---
Survey: 2025-11-20 | Tag F0692 | Quality of Life and Care Deficiencies | Severity: D
Provide enough food/fluids to maintain a resident's health.
---
Survey: 2025-11-20 | Tag F0770 | Administration Deficiencies | Severity: D
Provide timely, quality laboratory services/tests to meet the needs of residents.
---
Survey: 2025-11-20 | Tag F0773 | Administration Deficiencies | Severity: D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
---
Survey: 2025-11-20 | Tag F0775 | Administration Deficiencies | Severity: E
Keep complete, dated laboratory records in the resident's record.
---
Survey: 2025-11-20 | Tag F0804 | Nutrition and Dietary Deficiencies | Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
---
Survey: 2025-11-20 | Tag F0805 | Nutrition and Dietary Deficiencies | Severity: D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
---
Survey: 2025-11-20 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
---
Survey: 2025-11-20 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
---
Survey: 2025-11-20 | Tag F0887 | Infection Control Deficiencies | Severity: E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
---
Survey: 2024-10-24 | Tag F0684 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
---
Survey: 2024-02-22 | Tag F0550 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
---
Survey: 2024-02-22 | Tag F0558 | Resident Rights Deficiencies | Severity: D
Reasonably accommodate the needs and preferences of each resident.
---
Survey: 2024-02-22 | Tag F0565 | Resident Rights Deficiencies | Severity: E
Honor the resident's right to organize and participate in resident/family groups in the facility.
---
Survey: 2024-02-22 | Tag F0578 | Resident Rights Deficiencies | Severity: G
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.
---
Survey: 2024-02-22 | Tag F0580 | Resident Rights Deficiencies | Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
---
Survey: 2024-02-22 | Tag F0584 | Resident Rights Deficiencies | Severity: E
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.
---
Survey: 2024-02-22 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
---
Survey: 2024-02-22 | Tag F0607 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
---
Survey: 2024-02-22 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
---
Survey: 2024-02-22 | Tag F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Respond appropriately to all alleged violations.
---
Survey: 2024-02-22 | Tag F0624 | Resident Rights Deficiencies | Severity: G
Prepare residents for a safe transfer or discharge from the nursing home.
---
Survey: 2024-02-22 | Tag F0644 | Resident Assessment and Care Planning Deficiencies | Severity: E
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
---
Survey: 2024-02-22 | Tag F0657 | Resident Assessment and Care Planning Deficiencies | Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
---
Survey: 2024-02-22 | Tag F0660 | Resident Assessment and Care Planning Deficiencies | Severity: D
Plan the resident's discharge to meet the resident's goals and needs.
---
Survey: 2024-02-22 | Tag F0676 | Quality of Life and Care Deficiencies | Severity: E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
---
Survey: 2024-02-22 | Tag F0679 | Quality of Life and Care Deficiencies | Severity: D
Provide activities to meet all resident's needs.
---
Survey: 2024-02-22 | Tag F0687 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate foot care.
---
Survey: 2024-02-22 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
---
Survey: 2024-02-22 | Tag F0690 | Quality of Life and Care Deficiencies | Severity: G
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
---
Survey: 2024-02-22 | Tag F0692 | Quality of Life and Care Deficiencies | Severity: D
Provide enough food/fluids to maintain a resident's health.
---
Survey: 2024-02-22 | Tag F0694 | Quality of Life and Care Deficiencies | Severity: D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
---
Survey: 2024-02-22 | Tag F0695 | Quality of Life and Care Deficiencies | Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
---
Survey: 2024-02-22 | Tag F0697 | Quality of Life and Care Deficiencies | Severity: G
Provide safe, appropriate pain management for a resident who requires such services.
---
Survey: 2024-02-22 | Tag F0725 | Nursing and Physician Services Deficiencies | Severity: E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
---
Survey: 2024-02-22 | Tag F0726 | Nursing and Physician Services Deficiencies | Severity: J
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.
---
Survey: 2024-02-22 | Tag F0728 | Nursing and Physician Services Deficiencies | Severity: E
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
---
Survey: 2024-02-22 | Tag F0740 | Quality of Life and Care Deficiencies | Severity: G
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
---
Survey: 2024-02-22 | Tag F0745 | Quality of Life and Care Deficiencies | Severity: D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
---
Survey: 2024-02-22 | Tag F0757 | Pharmacy Service Deficiencies | Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
---
Survey: 2024-02-22 | Tag F0758 | Pharmacy Service Deficiencies | Severity: E
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.
---
Survey: 2024-02-22 | Tag F0760 | Pharmacy Service Deficiencies | Severity: D
Ensure that residents are free from significant medication errors.
---
Survey: 2024-02-22 | Tag F0761 | Pharmacy Service Deficiencies | Severity: E
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.
---
Survey: 2024-02-22 | Tag F0770 | Administration Deficiencies | Severity: D
Provide timely, quality laboratory services/tests to meet the needs of residents.
---
Survey: 2024-02-22 | Tag F0804 | Nutrition and Dietary Deficiencies | Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
---
Survey: 2024-02-22 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
---
Survey: 2024-02-22 | Tag F0867 | Administration Deficiencies | Severity: H
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
---
Survey: 2024-02-22 | Tag F0880 | Infection Control Deficiencies | Severity: E
Provide and implement an infection prevention and control program.
---
Survey: 2024-02-22 | Tag F0881 | Infection Control Deficiencies | Severity: E
Implement a program that monitors antibiotic use.
---
Survey: 2024-02-22 | Tag F0908 | Environmental Deficiencies | Severity: D
Keep all essential equipment working safely.
---
Survey: 2024-02-22 | Tag F0919 | Environmental Deficiencies | Severity: D
Make sure that a working call system is available in each resident's bathroom and bathing area.
---
Survey: 2024-02-22 | Tag F0923 | Environmental Deficiencies | Severity: E
Have enough outside ventilation via a window or mechanical ventilation, or both.
---
Survey: 2024-02-22 | Tag F0947 | Nursing and Physician Services Deficiencies | Severity: E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
---
Survey: 2022-05-25 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
---
Survey: 2022-05-25 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
---
Survey: 2022-05-25 | Tag F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Respond appropriately to all alleged violations.
---
Survey: 2022-05-25 | Tag F0755 | Pharmacy Service Deficiencies | Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Source: U.S. Centers for Medicare & Medicaid Services. Data reflects the most recent available inspection.