Deficiency Records for Tanglewood Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Tanglewood Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-05-16 | 2023-05-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-18 | 2023-05-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-18 | 2023-05-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-18 | 2023-05-16 | 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 | 2023-04-18 | 2023-05-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-18 | 2023-05-16 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-18 | 2023-05-16 | 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 | 2023-04-18 | 2023-05-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-18 | 2023-05-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-18 | 2023-05-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-18 | 2023-05-16 | 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 | 2023-04-18 | 2023-05-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-18 | 2023-05-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-18 | 2023-05-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-18 | 2023-05-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-16 | 2023-05-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-04 | 2023-01-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-14 | 2022-05-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-14 | 2022-05-15 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-01-18 | 2022-03-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-12-08 | 2021-12-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-08 | 2021-12-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-08 | 2021-12-13 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-08 | 2021-12-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-08 | 2021-12-13 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-01-29 | 2020-02-07 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-29 | 2020-02-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-29 | 2020-02-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-29 | 2020-02-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-29 | 2020-02-07 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-12-09 | 2020-01-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-09 | 2020-01-08 | 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 | 2019-12-09 | 2020-01-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-09 | 2020-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-09 | 2020-01-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-09 | 2020-01-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-09 | 2020-01-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-09 | 2020-01-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-09 | 2020-01-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-09 | 2020-01-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-09 | 2020-01-08 | N |
