Tranquility Assisted Living Home.

“Based on record review and interview, the manager failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for two of four employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents.     Findings Include:     1.    A review of E1’s personnel record revealed no documentation of initial fall prevention and fall recovery training. Based on E1's hire date (November 2025), this documentation was required.   2.    A review of E4’s personnel record revealed no documentation of initial fall prevention and fall recovery training. Based on E4's hire date (May 2025), this documentation was required.   3.    In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.     Findings include:      1. A documentation review of the facility’s policies and procedures manual stated, "A manager will ensure the policy statements and procedures are established, documented, and implemented and available for individuals providing services for the facility. Subsequently reviewed, every three years and updated as needed thereafter."     2. A documentation review of the signature page of the policy and procedure manual revealed it was last signed by the manager on January 30, 2019.     3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, and completed no later than 14 calendar days after the resident’s date of acceptance for one out of two residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident.     Findings include:   1.   A review of R1's medical record revealed a service plan; however, the service plan was not completed within 14 calendar days after the resident's date of acceptance.   2.    In an exit interview, the findings were reviewed with E1, and no additional information was provided.”