🔎 Meadowbrook Behavioral Health Center
Inspection Results
Inspection Overview
Meadowbrook Behavioral Health Center has been cited for a total of 61 deficiencies since we began saving each survey.
In California, the average facility has **64.18 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: H
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Scope/Severity: E
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
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.
Scope/Severity: D
Post nurse staffing information every day.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: E
Keep all essential equipment working safely.
Scope/Severity: B
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Scope/Severity: B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Scope/Severity: E
Respond appropriately to all alleged violations.
Scope/Severity: D
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.
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: E
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.
Scope/Severity: D
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.
Scope/Severity: D
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.
Scope/Severity: F
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.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: E
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Scope/Severity: B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Scope/Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity: D
Assess the resident when there is a significant change in condition
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: E
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.
Scope/Severity: D
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.
Scope/Severity: D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: B
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Scope/Severity: B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Scope/Severity: D
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.
Scope/Severity: D
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.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: D
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/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.
Scope/Severity: D
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.
Scope/Severity: D
Observe each nurse aide's job performance and give regular training.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/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.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: B
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Scope/Severity: B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Scope/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.
Scope/Severity: D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/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.
Scope/Severity: E
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Implement a program that monitors antibiotic use.
Scope/Severity: B
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Scope/Severity: B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**