Ann Pearl Nursing Facility

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and interventions resulting in 2 elopement incidents (01/19/26 and 01/28/26) for Resident (R) 36. This deficient practice created the likelihood for a serious adverse outcome (e.g. serious bodily injury and /or death from being hit by a car) due to open access to a busy road from the facility entrance and adjacent parking lot.

Inspectors wroteBased on interviews and record review, the facility failed to prevent potential abuse for one of three residents sampled for abuse (Resident (R) 12) and other residents at risk due to delayed initiation of the investigation for R12's allegation of abuse. As a result of this deficient practice, the residents were placed at a potential risk for physical and psychosocial harm.

Inspectors wroteBased on interviews and record review, the facility failed to consult with the physician for worsening injury sustained after a fall, which required a physician's intervention for one of three residents (Resident (R)19) sampled for falls. As a result of this deficient practice, the resident was at risk for more than minimal physical harm. Findings Include: On 03/19/25 at 02:27 PM, conducted a review of R19's Electronic Health Record (EHR). Review of the progress notes documented: -01/25/25 at 02:45 PM, At 1120, the writer heard resident calling out. Upon arrival to room, resident found on floor next to bed lying on back . c/o (complained of) pain to right forearm only. Right forearm with full ROM (range of motion) though resident is moving it weakly related to pain. Notified .on-call provider (OCP1) . with no new orders received . [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure for one of three residents (Resident (R) 12) sampled for abuse, that alleged violations are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This deficient practice resulted in the facility not implementing its policy and procedure to ensure the immediate safety of the alleged victim, timely reporting of an alleged crime, and a timely abuse investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, as evidenced by five medication errors observed out of 31 opportunities for errors, for an error rate of 16%. Safe and timely medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, three residents (Residents (R) 37, R7, and R52) were placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications administered by staff.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered trauma-informed care (TIC) care plan for one of one resident (Resident (R) 41) reviewed with a diagnosis of Post Traumatic Stress Disorder (PTSD). As a result of this deficient practice, the facility staff did not have sufficient information to meet the R41's needs.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for one of one sampled resident (Resident (R) 42) for elopement. This deficient practice has the potential to place R42 at risk for future elopements.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure one of two residents (Resident (R)12) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services to maintain and/or prevent a decline in ROM in her left hand and elbow, as evidenced by inconsistent application of orthotic devices and ROM exercises. As a result of this deficient practice, R12 was placed at risk of a decline in ROM and a loss of function.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents remain as free of accident hazards as possible for two of six residents (Resident (R) 35 and R42) sampled for accidents. The facility failed to identify and eliminate a known and foreseeable accident hazard in the resident environment (wet floor); failed to lock up R35's cigarettes and lighter; and failed to ensure R42's seizure pads were in place. The deficient practices have the potential for ambulatory residents on the unit to sustain a preventable injury; the potential of a fire accident in the facility that has residents who are on oxygen; and the potential for R42 sustaining injuries in bed when having a seizure.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the physician ordered oxygen therapy during assistance with a meal for one of two residents (Resident (R) 2) sampled for oxygen use. This deficient practice has the potential for R2 to encounter difficulty breathing and discomfort.

Inspectors wroteBased on interviews and record reviews, the facility failed to adequately assess for and identify past trauma experienced by one of one residents (Resident (R) 41) sampled for trauma-informed care (TIC). As a result of this deficient practice, R41 did not have her trauma triggers identified, placing her at increased risk of re-traumatization, and was hindered from attaining her highest practicable mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medication regimen irregularities/recommendations were addressed by the physician for one of five residents (Resident (R) 7) sampled for unnecessary medications. As a result of this deficient practice, R7 was placed at risk of avoidable complications related to continuing an as needed psychotropic (a drug taken to exert an effect on the chemical makeup of the brain and nervous system) past 14 days without a clinical rationale.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection prevention and control measures for one of two residents (Resident (R) 35) sampled for Transmission Based Precautions (TBP). The facility did not ensure nursing staff hand hygiene between glove use while providing wound care for R35. This deficient practice has the potential to put residents at risk of spreading infections and communicable diseases.

Inspectors wroteBased on interviews, document and record review (RR), the facility failed to provide one Resident (R)1 the right to equal access of quality care. Specifically, R1's primary language was Korean and the facility did not have an effective process in place to access interpreters. Due to this deficiency, staff were unable to communicate and understand R1's needs to provide her the quality of care she had the right to. This deficiency has the potential to affect any resident whose primary language is not English. Without appropriate communication, the resident's may not meet their highest level of physical and psychosocial well-being.

Inspectors wroteBased on interviews, document review and medical record review (RR), the facility failed to ensure a person-centered comprehensive care plan (CP) was developed to address one resident's (R)1 needs of a sample size of three. R1 had significant hearing impairment, but the CP did not include this barrier to communication. As a result of this deficiency, the care team may not have been aware of her hearing impairment when interacting with her. There is a potential any resident may not reach their highest practical physical and psychosocial potential if their needs are not identified and addressed in the CP.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's (R)12's physician was notified after an incident that occurred resulted in an injury for one resident sampled. On 02/08/24, R12 reported that during physical therapy he experienced a loud crack and sharp pain to his hip when physical therapist (PT)1 pushed R12's left knee to the resident's chest. R12's physician and his treatment team were not notified of the incident which resulted in a left hip fracture that was delayed in diagnosis and treatment. On 02/26/24, R12 was transferred to a hospital for a surgical repair of the fracture. As a result of this deficient practice, R12 suffered pain, continued to decline and sustained harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the dignity of one of the 14 residents (R) in the sample. The urinary catheter bag for R101 was not covered and visible from the hallway, revealing his medical condition to other residents and visitors to the facility. This deficient practice has the potential to affect all residents in the facility with an indwelling urinary catheter.

Inspectors wroteBased on interview and record review, the facility failed to ensure an injury of unknown origin was thoroughly investigated for one resident sampled. On 02/25/24, the facility submitted a completed event report for resident (R)12 who sustained a left hip fracture, origin of the injury was not known. The investigation report did not include documentation of R12's incident during physical therapy that was reported to nursing staff. Interview of staff responsible for completing the investigation confirmed the facility was unaware of the resident's report and the incident during PT could have potentially been the source of R12's injury. The investigation was initiated by the facility after becoming aware of R12's left hip fracture. As a result of this deficient practice, the Resident experienced a delay in the diagnosis and treatment of a left hip fracture.

Inspectors wroteBased on observation, interview, and review of the facility's policy and procedure, the facility failed to ensure the controlled drug records were reconciled between shifts. The deficient practice potentially places the facility at risk for the diversion of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to label medications in accordance with acceptable professional standards. Proper labeling of medications is necessary for safe administration practices and to decrease the risk of medication errors. This deficient practice has the potential to affect all the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's infection prevention and control measures. The facility did not ensure the staff were wearing applicable personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP). This deficient practice placed all the residents at risk for the potential spread of infections and communicable diseases.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide services by sufficient numbers of nursing staff evidenced by long call light waiting times by the residents in the facility. The deficient practice has the potential to result in an increased risk for an adverse event for the residents residing in the facility.

Inspectors wroteThe facility failed to implement its performance improvement project for a problem prone area when the untimely call response times were identified. The deficient practice has the potential to adversely affect the residents residing in the facility.

Inspectors wroteBased on observations, interview and record review, the facility failed to update the care plans (CP) for three dependent residents with a diagnosis of dementia in the sample, who had multiple falls. Resident's (R)10, 12, and 14. The deficient practice placed the residents at an increased risk for injury. In addition, the facility did not revise R1's CP to include notifying the provider if her systolic blood pressure (SBP) was over 160. This increased the risk that the provider would not be notified R1's BP was outside desired parameters.

Inspectors wroteBased on interviews and record review (RR), the facility nursing staff did not display the competencies and necessary skill set when monitoring one resident's (R)1 blood pressure to meet the residents needs safely. Specifically the staff did not notify the provider as ordered when her systolic blood pressure was out of parameters. This put R1 at higher risk that her hypertension would not be managed effectively.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to ensure one of 22 residents (Resident (R) 20) sampled was free from accident hazards from the use of an electric heating pad. As a result of this deficient practice, R20 sustained second-degree burns to both left and right calf areas.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Medical Director (MD) was responsible for coordination of medical care in the facility, including the oversight of other practitioner practicing in the facility.

Inspectors wroteBased on observations and interviews with staff member, the facility failed to provide a homelike environment for residents. The facility failed to remove trays when passing meals to residents. The facility failed to repair water damage due to water leakage from the roof in three residents (Resident (R) 9, R2, and R61) in one nursing unit As a result of this deficiency, resident is at risk of a negative psychosocial outcome.

Inspectors wroteBased on record review, staff interview and review of the COVID-19 Risk Mitigation Plan, the facility failed to provide COVID-19 vaccine education for two Residents (R) 25, R42 of the five residents sampled. As a result of this deficiency, the facility did not meet the regulation for providing education regarding benefits and potential risks associated with the vaccination.

Inspectors wroteBased on observations, staff interviews, policy review, record review, the facility failed to ensure three of 22 sampled residents (Resident (R) 48, R36, and R3) were treated with respect and dignity.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that required notices in the facility were easily readable for residents. This deficient practice affects residents who can visualize the postings in the facility.

Inspectors wroteBased on record review and interview with staff member, the facility failed to assure one of four residents (R)46 sampled exercised their right to formulate an advanced health care directive (AHCD). This deficient practice has the potential to cause harm to residents when they are provided medical care that is not in accordance with their wishes.

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect one of 22 residents sampled from abuse. Resident (R) 20 sustained second degree burns from a heating pad, an item not allowed in the facility, left on her calves by a certified nurse aide (CNA). Finding Includes: Cross Reference to F609 (Reporting of Alleged Violations). The facility failed to report suspected neglect to the Stage Agency. F610 (Investigate/Prevent/Correct Alleged Violation). The facility failed to investigate and prevent further potential neglect after R20 sustained second-degree burns from the use of a heating pad. F689 (Free of Accident Hazards). The facility failed to ensure R20 was free from accident hazards from the use of an electric heating pad, sustain second-degree burns to both left and right calf areas. [...]

Inspectors wroteBased on interviews, record and policy review, the facility failed to report suspected abuse to the State Agency (SA) for resident (R) 20. As a result of this deficient practice the SA did not have information to determine if an investigation by the agency was needed, and there is the potential that incidents that are poorly investigated put all residents at risk for neglect.

Inspectors wroteBased on interviews and records review, the facility failed to thoroughly investigate and prevent further potential neglect after R20 sustained second-degree burns from the use of a heating pad. The lack of a thorough investigation and prevention could lead to a corrective action that is ineffective and would continue to put the residents at risk for preventable harm. Finding Includes: Cross Reference to F600 (Free from Abuse and Neglect). The facility failed to protect one of 22 residents sampled from abuse. Resident (R) 20 sustained second degree burns from a heating pad, an item not allowed in the facility, left on her calves by a certified nurse aide (CNA). Cross Reference to F609 (Reporting of Alleged Violations). The facility failed to report suspected neglect to the Stage Agency. Cross Reference to F689 (Free of Accident Hazards). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident's (Resident (R)8) comprehensive person-centered care plan was implemented. R8 has difficulty swallowing and requires staff supervision during meals for aspiration precaution, observations were made of R8 eating meals in his/her room with no staff present. As a result of this deficiency, the resident is at risk of harm from aspirating during meal(s).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to review and revise the comprehensive plan of care for three of 22 residents sampled (Resident (R) 7, R41 and R49). This deficient practice failed to effectively address the residents' status, condition, and needs, and therefore not assisting these residents attain their highest practicable physical and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure professional standards of practice were implemented for a resident (Resident(R)32) receiving supplemental oxygen. As a result of this deficient practice, residents on supplemental oxygen are at a potential of harm related to respiratory infection.

Inspectors wroteBased on observations, interviews, and record review (RR), the facility failed to ensure physician services adequately addressed the needs of one of 22 residents sampled (Resident (R) 24). Physicians are required to supervise medical care of residents by prescribing medications and therapy, participating in resident assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when contacted by the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide behavioral health care to one of 22 residents (R) sampled. R62 was not monitored for adverse effects or effectiveness of prescribed psychotropic (drugs affecting behavior, mood, thoughts, or perception) medications. This deficient practice has the potential to affect all residents on psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that an accurate account of controlled drugs is maintained and periodically reconciled. As a result of this deficiency, there is the potential for the of diversion of controlled drugs.

Inspectors wroteBased on observation, record reviews, and interview, the facility failed to adequately monitor medication for one resident (R), R37, of five residents sampled for unnecessary medications. As a result of this deficient practice, R37 was put at risk for adverse side effects of a psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications used in the facility were securely stored in locked compartments. Proper storage is necessary to decrease the risk of diversion of resident medications. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to assist Resident (R) 41 obtain routine dental care, including making an appointment, arrange for transportation to and from the dental service location, and if eligible, apply for reimbursement of dental services as incurred medical expense under the State plan.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure food was stored in in accordance with professional standards for food service safety.

Inspectors wroteBased on documentation, the facility failed to ensure a single resident bedroom measured at least one hundred square feet of usable space and ensure a multi-resident room provides a minimum space of eighty square feet per bed of unusable space, excluding closets, bathrooms, alcoves and entryways.