Ann Pearl Nursing Facility

In the surveyor’s words

From the most serious findings on record at Ann Pearl Nursing Facility, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Feb 17, 2021

  Based on observations, interviews, and record reviews, the facility failed to establish a prevention control program to provide safety and protection for the residents of the facility. Immediate Jeopardy (IJ) was identified on 02/09/21 at 01:06 PM, the facility failed to isolate and place a resident on droplet precautions when the resident presented with signs and symptoms (fever, nausea, vomiting, and chills) of COVID-19 and screened positively for a person under investigation. The facility's noncompliance could result in serious adverse outcomes (spread of COVID-19 to facility staff and other residents and possibility of COVID-19 related deaths). The need for immediate action was required to prevent a COVID-19 outbreak. […]

• Immediate jeopardy, isolatedF689Mar 12, 2026

  Based 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. Findings include:The Office of Health Care Assurance (OHCA) received a facility-reported incident (FRI) Intake #2721134, documenting an incident of elopement that occurred on 01/19/26 at 06:28 PM by R36. […]

• Actual harm, isolatedF580Mar 22, 2024

  Based 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. […]

• Actual harm, isolatedF689Mar 3, 2023

  Based 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. Findings include: 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). […]

• Actual harm, isolatedF684Mar 11, 2022

  Based on observations, record reviews and interviews, the facility failed to provide resident centered needed care and services for three residents, R159, R20, and R47, out of a total of 17 sampled residents. The facility did not follow the physician ordered bowel regimen for R159 and R20, which resulted in a family member performing digital stimulation on R159. R159 and R20 potentially suffered discomfort and fecal impaction. R47 did not receive the appropriate care for her swollen legs and monitoring of her left kneecap for possible displacement. These deficient practices could potentially affect all residents in the facility. Findings include: 1) R159 was admitted to the facility on [DATE] and discharged to home with hospice on 08/13/21. Residents' primary language is Korean. […]