A list of the most recent deficiencies for Accolade Hc of Paxton On Pells. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-01-18 | 2024-02-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-18 | 2024-02-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-18 | 2024-02-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-18 | 2024-02-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-20 | 2024-01-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-24 | 2023-10-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-24 | 2023-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-24 | 2023-10-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-24 | 2023-10-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-01 | 2023-08-11 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-01 | 2023-08-11 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| 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. | Health | 2023-05-26 | 2023-06-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-26 | 2023-06-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-05-26 | 2023-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-26 | 2023-06-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-01 | 2023-05-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-01 | 2023-05-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-01 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-01 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-05 | 2022-12-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-24 | 2022-09-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-24 | 2022-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-24 | 2022-09-16 | N |
| 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. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-24 | 2022-09-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-24 | 2022-09-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-24 | 2022-09-16 | N |
| 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. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-24 | 2022-09-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Develop a communication plan. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-01 | 2022-02-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-01 | 2022-02-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-01 | 2022-02-23 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-17 | 2021-12-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-17 | 2021-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-17 | 2021-12-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-17 | 2021-12-01 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-11-04 | 2021-11-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-04 | 2021-11-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-04 | 2021-11-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-04 | 2021-11-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-11-04 | 2021-11-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-04 | 2021-11-20 | N |
| 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. | Health | 2021-11-04 | 2021-11-20 | N |
| 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. | Health | 2021-11-04 | 2021-11-20 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-11-04 | 2021-11-20 | N |
| 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. | Health | 2021-11-04 | 2021-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-04 | 2021-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-04 | 2021-11-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-25 | 2021-09-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-25 | 2021-09-13 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-25 | 2021-09-13 | Y |
| 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. | Health | 2021-07-28 | 2021-08-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-03 | 2021-06-03 | Y |
