Care Citations

Accordius Health at Rose Manor LLC

4230 North Roxboro Street, Durham, NC, 27704 · 9194779805

On the CMS record

Overall rating (CMS)
2 / 5
Health inspection rating
2 / 5
Staffing rating
3 / 5
Certified beds
111
Ownership type
For profit - Limited Liability company
Chain
SIMCHA HYMAN & NAFTALI ZANZIPER

Inspection findings on record (38)

Quoted exactly as CMS published them. We do not rewrite findings.

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0925 · scope/severity F · potential for more than minimal harm

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity E · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0814 · scope/severity E · potential for more than minimal harm

Dispose of garbage and refuse properly.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0578 · scope/severity D · potential for more than minimal harm

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0607 · scope/severity D · potential for more than minimal harm

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0644 · scope/severity D · potential for more than minimal harm

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity D · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity D · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0688 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity B · potential for minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity J · immediate jeopardy

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0578 · scope/severity E · potential for more than minimal harm

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity E · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity E · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity E · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0809 · scope/severity E · potential for more than minimal harm

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity E · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0565 · scope/severity D · potential for more than minimal harm

Honor the resident's right to organize and participate in resident/family groups in the facility.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity B · potential for minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity B · potential for minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity B · potential for minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0908 · scope/severity F · potential for more than minimal harm

Keep all essential equipment working safely.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity E · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0637 · scope/severity D · potential for more than minimal harm

Assess the resident when there is a significant change in condition

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity D · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity D · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0921 · scope/severity C · potential for minimal harm

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity B · potential for minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 345081