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Deficiency Records for Annandale Healthcare Center
View the most recent health deficiencies and inspection results for Annandale Healthcare Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Annandale Healthcare Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-09 | 2025-01-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-09 | 2025-01-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-10-09 | 2024-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-10-09 | 2024-12-16 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-10-09 | 2024-11-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-09 | 2024-11-19 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-10-09 | 2024-11-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-10-09 | 2024-11-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-10-09 | 2024-11-19 | 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 | 2024-10-09 | 2024-11-19 | 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 | 2024-10-09 | 2024-11-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-10-09 | 2024-11-19 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-10-09 | 2024-11-19 | 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 | 2024-10-09 | 2024-11-19 | 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 | 2024-10-09 | 2024-11-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-10-09 | 2024-11-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-10-09 | 2024-11-19 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-10-09 | 2024-11-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-10-09 | 2024-11-19 | Y |
| 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 | 2024-10-09 | 2024-11-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-09 | 2024-11-19 | 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 | 2024-10-09 | 2024-11-19 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-10-09 | 2024-11-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-10-09 | 2024-11-19 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-10-09 | 2024-11-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-09 | 2024-11-19 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-10-09 | 2024-11-19 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-10-09 | 2024-11-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-10-09 | 2024-11-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-10-09 | 2024-11-19 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-10-09 | 2024-11-19 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-10-09 | 2024-11-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-10-09 | 2024-11-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-10-09 | 2024-11-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-10-09 | 2024-11-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-10-09 | 2024-11-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-10-09 | 2024-11-19 | 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 | 2024-10-09 | 2024-11-19 | 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 |
| 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 |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2021-03-05 | 2021-07-01 | N |
| 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 |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-03-05 | 2021-04-21 | N |
| Provide and implement an infection prevention and control program. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-23 | 2018-12-06 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | 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 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 |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-23 | 2018-09-26 | 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 |
| 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 |