A list of the most recent deficiencies for Accordius Health at Hendersonville. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-11-15 | 2023-12-15 | 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 | 2023-11-15 | 2023-12-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-15 | 2023-12-15 | N |
| Provide appropriate foot care. | Health | 2023-10-13 | 2023-11-03 | 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 | 2023-10-13 | 2023-11-03 | N |
| Provide or obtain dental services for each resident. | Health | 2023-10-13 | 2023-11-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-13 | 2023-11-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-13 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-13 | 2023-11-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-13 | 2023-11-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-13 | 2023-11-03 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-08 | 2022-12-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-20 | 2022-09-28 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-11 | 2022-09-28 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-07-11 | 2022-09-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-11 | 2022-09-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-11 | 2022-09-28 | 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 | 2022-07-11 | 2022-09-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-11 | 2022-09-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-11 | 2022-09-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-11 | 2022-09-28 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-11 | 2022-09-28 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-08-10 | 2022-09-20 | 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 | 2022-08-10 | 2022-09-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-10 | 2022-09-20 | 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 | 2022-08-10 | 2022-09-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-10 | 2022-09-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-07-11 | 2022-08-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-11 | 2022-08-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-31 | 2022-02-11 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-08-25 | 2021-09-17 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-13 | 2021-09-04 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-23 | 2021-08-10 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-23 | 2021-08-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-23 | 2021-08-10 | 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 | 2021-07-23 | 2021-08-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-23 | 2021-08-10 | Y |
