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Deficiency Records for Tranquility Nursing and Rehab
A list of the most recent deficiencies for Tranquility Nursing and Rehab. 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 Tranquility Nursing and Rehab. 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? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-08-26 | 2024-10-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-26 | 2024-10-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-26 | 2024-10-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-26 | 2024-10-15 | 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 | 2024-08-26 | 2024-10-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-26 | 2024-10-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-08-26 | 2024-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-08-26 | 2024-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-26 | 2024-10-15 | 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 | 2024-08-08 | 2024-10-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-08 | 2024-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-08 | 2024-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-08 | 2024-10-04 | 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 | 2024-08-08 | 2024-10-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-08 | 2024-10-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-08 | 2024-10-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-08 | 2024-08-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-08 | 2024-08-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-08 | 2024-08-31 | N |
| Respond appropriately to all alleged violations. | Health | 2024-08-08 | 2024-08-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-08 | 2024-08-31 | 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 | 2024-08-08 | 2024-08-31 | N |
| Provide activities to meet all resident's needs. | Health | 2024-08-08 | 2024-08-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-08 | 2024-08-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-08-08 | 2024-08-31 | 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 | 2024-08-08 | 2024-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-08 | 2024-08-31 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-08-08 | 2024-08-31 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-08-08 | 2024-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-08 | 2024-08-31 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-08-08 | 2024-08-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-06 | 2024-06-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-06 | 2024-06-28 | Y |
| 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 | 2024-06-06 | 2024-06-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-06-06 | 2024-06-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-09 | 2024-06-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-09 | 2024-06-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-09 | 2024-06-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-09 | 2024-06-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-09 | 2024-06-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-20 | 2024-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-20 | 2024-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-20 | 2024-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-20 | 2024-04-05 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-03-20 | 2024-04-05 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-03-20 | 2024-04-05 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-04 | 2024-01-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-04 | 2024-01-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-04 | 2024-01-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-30 | 2023-12-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | 2023-12-04 | Y |
| 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 | 2023-11-30 | 2023-12-04 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-11-30 | 2023-12-04 | Y |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2023-07-07 | 2023-09-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-07 | 2023-09-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-07-07 | 2023-09-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-07 | 2023-09-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-07 | 2023-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-07 | 2023-09-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-07 | 2023-09-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-07 | 2023-09-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-07 | 2023-09-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-15 | 2023-07-15 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-15 | 2023-07-15 | 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 | 2023-06-15 | 2023-07-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-06-15 | 2023-07-15 | 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 | 2023-06-15 | 2023-07-15 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-06-15 | 2023-07-15 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-06-15 | 2023-07-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-15 | 2023-07-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-15 | 2023-07-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-15 | 2023-07-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-20 | 2022-01-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-20 | 2022-01-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-19 | 2021-11-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-19 | 2021-11-11 | 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 | 2021-08-19 | 2021-11-11 | 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 | 2021-08-19 | 2021-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-11-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-09-07 | 2021-10-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-07 | 2021-10-04 | 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 | 2021-09-07 | 2021-10-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-07 | 2021-10-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-09-07 | 2021-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-07 | 2021-10-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-09-07 | 2021-10-04 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-09-07 | 2021-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-07 | 2021-10-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-07 | 2021-10-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-07 | 2021-10-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-19 | 2021-09-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-08-19 | 2021-09-22 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-08-19 | 2021-09-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-19 | 2021-09-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-19 | 2021-09-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-08-19 | 2021-09-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-19 | 2021-09-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-19 | 2021-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-09-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-08-19 | 2021-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-09-22 | N |
| Report COVID19 data to residents and families. | Health | 2021-08-19 | 2021-09-22 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-19 | 2021-09-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-08-19 | 2021-09-22 | N |
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