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🔎 Accordius Health At Hendersonville

Inspection Results


Inspection Overview

Accordius Health At Hendersonville has been cited for a total of 67 deficiencies since we began saving each survey.

In North Carolina, the average facility has **29.80 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: C

Ensure the activities program is directed by a qualified professional.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Assure that each resident’s assessment is updated at least once every 3 months.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: B

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: F

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: B

Provide bedrooms that don't allow residents to see each other when privacy is needed.

Survey Date: 2024-12-06
Correction Date: 2025-01-03
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-06-21
Correction Date: 2024-06-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-06-21
Correction Date: 2024-06-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: C

Hire a qualified full-time social worker in a facility with more than 120 beds.

Survey Date: 2024-06-21
Correction Date: 2024-07-09
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: E

Provide appropriate foot care.

Survey Date: 2023-10-13
Correction Date: 2023-11-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-10-13
Correction Date: 2023-11-03
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide or obtain dental services for each resident.

Survey Date: 2023-10-13
Correction Date: 2023-11-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-10-13
Correction Date: 2023-11-03
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2023-10-13
Correction Date: 2023-11-03
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2023-10-13
Correction Date: 2023-11-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2023-10-13
Correction Date: 2023-11-03
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2023-10-13
Correction Date: 2023-11-03
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: B

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2022-12-08
Correction Date: 2022-12-23
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2022-10-20
Correction Date: 2022-09-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2022-07-11
Correction Date: 2022-09-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2022-07-11
Correction Date: 2022-09-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: B

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2022-07-11
Correction Date: 2022-08-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2022-07-11
Correction Date: 2022-09-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-07-11
Correction Date: 2022-09-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-07-11
Correction Date: 2022-09-28
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2022-07-11
Correction Date: 2022-09-28
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: F

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

Survey Date: 2022-07-11
Correction Date: 2022-09-28
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: B

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

Survey Date: 2022-07-11
Correction Date: 2022-08-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2022-07-11
Correction Date: 2022-09-28
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2022-07-11
Correction Date: 2022-09-28
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2022-01-31
Correction Date: 2022-02-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2021-08-13
Correction Date: 2021-09-04
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2021-07-23
Correction Date: 2021-08-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-07-23
Correction Date: 2021-08-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-07-23
Correction Date: 2021-08-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-07-23
Correction Date: 2021-08-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2021-07-23
Correction Date: 2021-08-10
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-10-16
Correction Date: 2020-11-08
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-06-25
Correction Date: 2020-07-22
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Dispose of garbage and refuse properly.

Survey Date: 2019-05-16
Correction Date: 2019-06-13
Category: Nutrition and Dietary Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**