A list of the most recent deficiencies for Accordius Health at Wilmington. 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? |
|---|---|---|---|---|
| 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 | 2023-11-20 | 2023-12-05 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-20 | 2023-12-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-20 | 2023-10-07 | 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 | 2023-02-16 | 2023-03-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-16 | 2023-03-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-20 | 2023-02-20 | N |
| 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 | 2023-01-20 | 2023-02-20 | N |
| Post nurse staffing information every day. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-20 | 2023-02-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-20 | 2023-02-20 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-20 | 2023-02-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-08 | 2023-02-20 | 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 | 2022-11-08 | 2023-02-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-08 | 2023-01-20 | 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 | 2022-11-08 | 2022-12-12 | Y |
| Report COVID19 data to residents and families. | Health | 2022-11-08 | 2022-12-12 | 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 | 2022-04-21 | 2022-05-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-21 | 2022-05-16 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-19 | 2021-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-19 | 2021-12-17 | 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 | 2021-11-19 | 2021-12-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-19 | 2021-12-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-19 | 2021-12-17 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-19 | 2021-12-17 | 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 | 2019-08-07 | 2019-09-21 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-08-07 | 2019-09-21 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-08-07 | 2019-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-07 | 2019-09-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-07 | 2019-09-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-11 | 2019-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-11 | 2019-08-30 | 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 | 2019-07-11 | 2019-08-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-11 | 2019-08-30 | N |
