A list of the most recent deficiencies for Pearl at The Tillers. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-19 | 2023-04-01 | 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 | 2023-03-23 | 2023-03-30 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-19 | 2023-02-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-19 | 2023-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-19 | 2023-01-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-12 | 2023-01-30 | 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 | 2023-01-12 | 2023-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-01-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-19 | 2023-01-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-12 | 2023-01-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-12 | 2023-01-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-12 | 2023-01-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-01-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-12 | 2023-01-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-12 | 2023-01-27 | 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 | 2023-01-12 | 2023-01-24 | 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 | 2023-01-19 | 2023-01-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-20 | 2021-10-29 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-09-20 | 2021-10-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-09-20 | 2021-10-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-09-20 | 2021-10-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-20 | 2021-10-29 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-09-20 | 2021-10-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-20 | 2021-10-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-20 | 2021-10-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-20 | 2021-10-29 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-09-20 | 2021-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-27 | 2021-09-15 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-08-27 | 2021-09-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-27 | 2021-09-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-27 | 2021-09-15 | 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 | 2021-08-27 | 2021-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-09-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-10 | 2021-06-25 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-06-10 | 2021-06-25 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-06-10 | 2021-06-25 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-01 | 2019-12-24 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-11-01 | 2019-12-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-11-01 | 2019-12-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-11-01 | 2019-12-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-01 | 2019-12-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-01 | 2019-12-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-01 | 2019-12-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-01 | 2019-12-17 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-11-01 | 2019-12-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-01 | 2019-11-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-01 | 2019-11-23 | 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 | 2019-11-01 | 2019-11-20 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-11-01 | 2019-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-01 | 2019-11-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-01 | 2019-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-01 | 2019-11-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-11-01 | 2019-11-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-01 | 2019-11-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-23 | 2019-10-28 | 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 | 2019-10-23 | 2019-10-28 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-10-23 | 2019-10-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-10-23 | 2019-10-28 | N |
