A list of the most recent deficiencies for Accordius Health at Monroe. 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? |
|---|---|---|---|---|
| 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 | 2024-01-04 | 2024-02-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-04 | 2024-02-08 | 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 | 2024-01-04 | 2024-02-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-04 | 2024-02-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-30 | 2023-12-20 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-11-30 | 2023-12-20 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-30 | 2023-09-07 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-07-14 | 2022-08-28 | 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 | 2022-07-14 | 2022-08-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-14 | 2022-08-28 | 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 | 2022-06-17 | 2022-07-01 | 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 | 2022-06-17 | 2022-07-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-17 | 2022-07-01 | 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 | 2022-06-17 | 2022-07-01 | 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 | 2022-06-17 | 2022-07-01 | 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 | 2022-06-17 | 2022-07-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-17 | 2022-07-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-06-17 | 2022-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-17 | 2022-07-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-17 | 2022-07-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-17 | 2022-07-01 | Y |
| Construct fire resistant interior walls. | Fire Safety | 2020-03-04 | 2020-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-04 | 2020-03-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-03-04 | 2020-03-22 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2020-03-04 | 2020-03-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-04 | 2020-03-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-13 | 2020-03-11 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2020-02-13 | 2020-03-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-13 | 2020-03-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-13 | 2020-03-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-13 | 2020-03-11 | 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 | 2020-02-13 | 2020-03-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-13 | 2020-03-11 | N |
| Post nurse staffing information every day. | Health | 2020-02-13 | 2020-03-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-13 | 2020-03-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-13 | 2020-03-11 | 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 | 2020-02-13 | 2020-03-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-13 | 2020-03-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-13 | 2020-03-11 | N |
