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? |
|---|---|---|---|---|
| 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 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-19 | 2021-11-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-05 | 2021-11-11 | 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 | 2021-10-05 | 2021-11-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-17 | 2021-11-11 | Y |
| 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 | 2021-10-05 | 2021-10-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-17 | 2021-10-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-17 | 2021-10-08 | Y |
| 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 appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-19 | 2021-09-22 | Y |
| 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 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-06 | 2021-05-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-06 | 2021-05-24 | Y |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-04-03 | 2019-04-19 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Meet other general requirements. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
| Have a properly installed medical gas master alarm panel. | Fire Safety | 2019-04-03 | 2019-04-18 | N |
