A list of the most recent deficiencies for Accordius Health at Rose Manor LLC. 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-29 | 2024-02-22 | N |
| 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. | Health | 2024-01-29 | 2024-02-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-29 | 2024-02-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-29 | 2024-02-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-29 | 2024-02-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-29 | 2024-02-22 | 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 | 2024-01-29 | 2024-02-22 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-01-29 | 2024-02-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-29 | 2024-02-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-29 | 2024-02-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-29 | 2024-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-29 | 2024-02-22 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-29 | 2024-02-22 | Y |
| 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 | 2024-01-29 | 2024-02-22 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-01-31 | 2023-02-21 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-12 | 2023-01-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-12 | 2023-01-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-12 | 2023-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-12 | 2023-01-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-12 | 2023-01-20 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-16 | 2022-10-14 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-09-16 | 2022-10-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-16 | 2022-10-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-16 | 2022-10-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-16 | 2022-10-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-16 | 2022-10-14 | 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 | 2022-09-16 | 2022-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-16 | 2022-10-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-16 | 2022-10-14 | N |
| Keep all essential equipment working safely. | Health | 2022-09-16 | 2022-10-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-16 | 2022-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-16 | 2022-10-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-16 | 2022-10-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-16 | 2022-10-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-09 | 2022-03-31 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-03-09 | 2022-03-31 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-09 | 2022-03-31 | Y |
| 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 | 2022-03-09 | 2022-03-31 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-09 | 2022-03-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-09 | 2022-03-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-11 | 2021-05-21 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-06-19 | 2019-07-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-19 | 2019-07-18 | 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 | 2019-06-19 | 2019-07-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-19 | 2019-07-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-19 | 2019-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-19 | 2019-07-18 | N |
