A list of the most recent deficiencies for Ann Pearl Nursing Facility. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-19 | 2024-02-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-19 | 2024-02-18 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-01-19 | 2024-02-18 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-19 | 2024-02-18 | Y |
| 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. | Health | 2023-03-03 | 2023-04-26 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-03-03 | 2023-04-12 | 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 | 2023-03-03 | 2023-04-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-03 | 2023-04-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-03 | 2023-04-12 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-03 | 2023-04-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-03 | 2023-04-12 | 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 | 2023-03-03 | 2023-04-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-03 | 2023-04-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-03 | 2023-04-12 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-03-03 | 2023-04-12 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-03 | 2023-04-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-03 | 2023-04-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-03 | 2023-04-12 | 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 | 2023-03-03 | 2023-04-12 | N |
| Provide or obtain dental services for each resident. | Health | 2023-03-03 | 2023-04-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-03 | 2023-04-12 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-03-03 | 2023-04-12 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-03-03 | 2023-04-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-03-03 | 2023-04-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-03 | 2023-04-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-08 | 2023-04-06 | N |
| 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. | Health | 2022-03-11 | 2022-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-25 | N |
| Post nurse staffing information every day. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-11 | 2022-04-25 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-03-11 | 2022-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-11 | 2022-04-25 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-11 | 2022-04-25 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-11 | 2022-04-25 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-11 | 2022-04-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-11 | 2022-04-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-11 | 2022-04-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-11 | 2022-04-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-11 | 2022-04-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-24 | 2022-04-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-24 | 2022-04-25 | N |
| 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 | 2021-02-05 | 2021-06-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-05 | 2021-06-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-02-17 | 2021-04-09 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-02-17 | 2021-04-09 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-02-17 | 2021-04-09 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-02-17 | 2021-04-09 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-02-17 | 2021-04-09 | 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 | 2021-02-17 | 2021-04-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-02-17 | 2021-04-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-17 | 2021-04-09 | 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 | 2021-02-17 | 2021-04-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-17 | 2021-04-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-17 | 2021-04-09 | 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 | 2021-02-17 | 2021-04-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-17 | 2021-04-09 | 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 | 2021-02-17 | 2021-04-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-02-17 | 2021-04-09 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-02-17 | 2021-04-09 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-02-17 | 2021-04-09 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-02-17 | 2021-04-09 | 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 | 2021-02-17 | 2021-04-09 | 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 | 2021-02-17 | 2021-04-09 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-02-17 | 2021-04-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-02-17 | 2021-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-17 | 2021-04-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-02-17 | 2021-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-17 | 2021-04-09 | N |
