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Deficiency Records for Accolade Hc of Paxton On Pells
A list of the most recent deficiencies for Accolade Hc of Paxton On Pells. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Accolade Hc of Paxton On Pells. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-05 | 2024-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-01 | 2024-07-19 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-05-06 | 2024-05-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-06 | 2024-05-22 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-20 | 2024-04-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-20 | 2024-04-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-20 | 2024-04-05 | 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 | 2024-03-20 | 2024-04-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-20 | 2024-04-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-20 | 2024-04-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-20 | 2024-04-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-03-20 | 2024-04-05 | N |
| Post nurse staffing information every day. | Health | 2024-03-20 | 2024-04-05 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-03-20 | 2024-04-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-20 | 2024-04-05 | 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 | 2024-03-20 | 2024-04-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-03-20 | 2024-04-05 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-03-20 | 2024-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-20 | 2024-04-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-20 | 2024-04-05 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-03-20 | 2024-04-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-03-20 | 2024-04-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-20 | 2024-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-20 | 2024-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-10 | 2024-03-26 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2024-03-20 | 2024-03-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-03-20 | 2024-03-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-20 | 2024-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-20 | 2024-03-20 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-01-18 | 2024-02-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-18 | 2024-02-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-18 | 2024-02-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-18 | 2024-02-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-20 | 2024-01-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-24 | 2023-10-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-24 | 2023-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-24 | 2023-10-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-24 | 2023-10-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-01 | 2023-08-11 | Y |
| 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 | 2023-08-01 | 2023-08-11 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-22 | 2023-06-29 | 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 | 2023-05-26 | 2023-06-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-26 | 2023-06-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-05-26 | 2023-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-26 | 2023-06-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-01 | 2023-05-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-01 | 2023-05-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-01 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-01 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-05 | 2022-12-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-24 | 2022-09-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-24 | 2022-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-24 | 2022-09-16 | 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 | 2022-08-24 | 2022-09-16 | 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 | 2022-08-24 | 2022-09-16 | 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 | 2022-08-24 | 2022-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-24 | 2022-09-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-24 | 2022-09-16 | 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 | 2022-08-24 | 2022-09-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-08-24 | 2022-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-24 | 2022-09-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Develop a communication plan. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-24 | 2022-09-16 | 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 | 2022-08-24 | 2022-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-24 | 2022-09-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-01 | 2022-02-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-01 | 2022-02-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-01 | 2022-02-23 | Y |
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