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Deficiency Records for Pearl's Ii Eden For Elders
A list of the most recent deficiencies for Pearl's Ii Eden For Elders. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pearl's Ii Eden For Elders. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-06-14 | 2023-07-28 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-06-14 | 2023-07-21 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-06-14 | 2023-07-21 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-06-14 | 2023-07-21 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-06-14 | 2023-07-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-14 | 2023-07-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-14 | 2023-07-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-14 | 2023-07-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-14 | 2023-07-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-14 | 2023-07-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-14 | 2023-07-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-14 | 2023-07-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-14 | 2023-07-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-14 | 2023-07-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-06-14 | 2023-07-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-14 | 2023-07-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-06-14 | 2023-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-14 | 2023-07-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-14 | 2023-07-21 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-04-14 | 2023-05-17 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Use approved construction type or materials. | Fire Safety | 2021-09-10 | 2021-12-16 | 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 | 2021-09-10 | 2021-12-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-10 | 2021-12-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-10 | 2021-11-18 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-09-10 | 2021-11-18 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-09-10 | 2021-11-18 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-09-10 | 2021-11-18 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-09-10 | 2021-11-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-09-10 | 2021-11-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-09-10 | 2021-11-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-10 | 2021-11-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-10 | 2021-11-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-10 | 2021-11-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-10 | 2021-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-10 | 2021-11-18 | 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 | 2021-09-10 | 2021-11-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-10 | 2021-11-18 | N |
| 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 | 2021-09-10 | 2021-11-18 | 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 | 2021-09-10 | 2021-11-18 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-09-10 | 2021-11-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-09-10 | 2021-11-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-10 | 2021-11-18 | 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 | 2021-09-10 | 2021-11-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-10 | 2021-11-18 | 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 | 2021-09-10 | 2021-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-10 | 2021-11-18 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-08-01 | Not Fixed | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-08-01 | Not Fixed | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-08-01 | Not Fixed | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-01 | Not Fixed | N |
| Respond appropriately to all alleged violations. | Health | 2024-08-01 | Not Fixed | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-01 | Not Fixed | 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 | 2024-08-01 | Not Fixed | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-01 | Not Fixed | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-01 | Not Fixed | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-01 | Not Fixed | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-08-01 | Not Fixed | N |
| 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 | 2024-08-01 | Not Fixed | 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 | 2024-08-01 | Not Fixed | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-08-01 | Not Fixed | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-08-01 | Not Fixed | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-01 | Not Fixed | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-01 | Not Fixed | 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 | 2024-08-01 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-01 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-01 | Not Fixed | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-08-01 | Not Fixed | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-08-01 | Not Fixed | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-01 | Not Fixed | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-08-01 | Not Fixed | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-01 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-01 | Not Fixed | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-08-01 | Not Fixed | N |
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