A list of the most recent deficiencies for Accordius Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-06-13 | 2023-09-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-13 | 2023-09-06 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-06-13 | 2023-09-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-13 | 2023-09-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-13 | 2023-09-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-13 | 2023-09-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-11 | 2023-05-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-05-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-11 | 2023-05-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-11 | 2023-05-19 | N |
| 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 | 2023-05-11 | 2023-05-19 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-05-11 | 2023-05-19 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-17 | 2022-04-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-17 | 2022-04-08 | 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 | 2022-03-17 | 2022-04-08 | 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 | 2022-03-17 | 2022-04-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-17 | 2022-04-08 | 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 | 2022-03-17 | 2022-04-08 | 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 | 2022-03-17 | 2022-04-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-17 | 2022-04-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-17 | 2022-04-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-08 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2020-02-26 | 2020-04-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-26 | 2020-04-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-26 | 2020-04-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-30 | 2020-02-14 | 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 | 2020-01-30 | 2020-02-14 | N |
