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🔎 Meadow Brook Rehabilitation And Nursing

Inspection Results


Inspection Overview

Meadow Brook Rehabilitation And Nursing has been cited for a total of 61 deficiencies since we began saving each survey.

In Utah, the average facility has **33.72 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 HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

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

Survey Date: 2024-10-24
Correction Date: 2024-12-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/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 Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/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 Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/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 Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: G

Prepare residents for a safe transfer or discharge from the nursing home.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: G

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

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.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/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 Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/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 Date: 2024-02-22
Correction Date: 2024-04-19
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/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 Date: 2024-02-22
Correction Date: 2024-04-19
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/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 Date: 2024-02-22
Correction Date: 2024-04-19
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

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.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/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 Date: 2024-02-22
Correction Date: 2024-04-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: H

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Keep all essential equipment working safely.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: E

Have enough outside ventilation via a window or mechanical ventilation, or both.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Environmental Deficiencies
From Complaint: Y

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.

Survey Date: 2024-02-22
Correction Date: 2024-04-19
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-05-25
Correction Date: 2022-07-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-05-25
Correction Date: 2022-07-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2022-05-25
Correction Date: 2022-07-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2022-05-25
Correction Date: 2022-07-15
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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 Date: 2019-12-18
Correction Date: 2020-02-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/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 Date: 2019-12-18
Correction Date: 2020-02-06
Category: Resident Rights Deficiencies
From Complaint: N

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.

Survey Date: 2019-12-18
Correction Date: 2020-02-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2019-12-18
Correction Date: 2020-02-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2019-12-18
Correction Date: 2020-02-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-12-18
Correction Date: 2020-02-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2018-11-29
Correction Date: 2019-01-25
Category: Resident Rights Deficiencies
From Complaint: N

Scope/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 Date: 2018-11-29
Correction Date: 2019-01-25
Category: Resident Rights Deficiencies
From Complaint: N

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.

Survey Date: 2018-11-29
Correction Date: 2019-01-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-11-29
Correction Date: 2019-01-25
Category: Pharmacy Service Deficiencies
From Complaint: N

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.

Survey Date: 2018-11-29
Correction Date: 2019-01-25
Category: Pharmacy Service Deficiencies
From Complaint: N

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.

Survey Date: 2018-11-29
Correction Date: 2019-01-25
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2018-11-29
Correction Date: 2019-01-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2018-11-29
Correction Date: 2019-01-25
Category: Environmental Deficiencies
From Complaint: N


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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.**