A list of the most recent deficiencies for Annandale Healthcare Center. 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2022-04-28 | 2022-04-28 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-03-05 | 2021-07-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-05 | 2021-07-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-05 | 2021-07-01 | 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 | 2021-03-05 | 2021-07-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-03-05 | 2021-07-01 | 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 | 2021-03-05 | 2021-07-01 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-05-27 | 2021-07-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-27 | 2021-07-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-27 | 2021-07-01 | 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 | 2021-05-27 | 2021-07-01 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-05-27 | 2021-07-01 | Y |
| 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 | 2021-05-27 | 2021-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-05 | 2021-05-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-05 | 2021-05-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-17 | 2021-04-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-03-17 | 2021-04-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-03-17 | 2021-04-21 | 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 | 2021-03-05 | 2021-03-29 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-03-05 | 2021-03-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-05 | 2021-03-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-03-05 | 2021-03-29 | N |
| Dispose of garbage and refuse properly. | Health | 2021-03-05 | 2021-03-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-05 | 2021-03-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-05 | 2021-03-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-04 | 2018-12-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-23 | 2018-09-26 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-08-23 | 2018-09-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-08-23 | 2018-09-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-23 | 2018-09-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-08-23 | 2018-09-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-23 | 2018-09-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-23 | 2018-09-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-23 | 2018-09-26 | 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 | 2018-08-23 | 2018-09-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-23 | 2018-09-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-08-23 | 2018-09-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Establish methods for sharing information. | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-23 | 2018-09-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-03-08 | 2017-04-24 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-03-02 | 2017-04-10 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-03-02 | 2017-04-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-02 | 2017-04-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-03-02 | 2017-04-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-02 | 2016-06-23 | N |
