A list of the most recent deficiencies for Accordius Health at Brevard. 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? |
|---|---|---|---|---|
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-14 | 2024-04-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-14 | 2024-03-30 | N |
| 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 | 2024-02-14 | 2024-03-30 | 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 | 2024-02-14 | 2024-03-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-14 | 2024-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-14 | 2024-03-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-14 | 2024-03-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-14 | 2024-03-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-14 | 2024-03-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-14 | 2024-03-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-14 | 2024-03-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-14 | 2024-03-30 | 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 | 2023-11-17 | 2023-12-15 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-17 | 2023-12-15 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-11-17 | 2023-12-15 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-11-17 | 2023-12-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-17 | 2023-12-15 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-17 | 2023-12-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-17 | 2023-12-15 | Y |
| 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 | 2023-11-17 | 2023-12-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-17 | 2023-12-15 | 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 | 2023-11-17 | 2023-12-15 | Y |
| 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 | 2023-11-17 | 2023-12-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-17 | 2023-12-15 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-17 | 2023-12-15 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Use approved construction type or materials. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Meet other general requirements. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-06-29 | 2022-09-14 | 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 | 2022-06-29 | 2022-09-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-29 | 2022-09-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-29 | 2022-09-14 | 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 | 2022-06-03 | 2022-06-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-03 | 2022-06-27 | 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 | 2022-06-03 | 2022-06-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-03 | 2022-06-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-03 | 2022-06-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-09-20 | 2022-04-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-20 | 2022-04-01 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-03-15 | 2022-03-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-20 | 2022-03-12 | Y |
| 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 | 2021-09-20 | 2021-11-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-20 | 2021-11-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-20 | 2021-11-12 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-09-20 | 2021-11-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-20 | 2021-11-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-20 | 2021-10-12 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-08 | 2021-07-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-08 | 2021-07-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-27 | 2020-03-26 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2020-02-27 | 2020-03-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-27 | 2020-03-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-27 | 2020-03-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-27 | 2020-03-26 | N |
