Inspection Reports for Tranquil Breezes Care Home, LLC
237 Palmetto Pointe Dr, Henderson, NV 89012, NV, 89012
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Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Feb 19, 2025
Visit Reason
The inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have no regulatory deficiencies and received a grade of A. Nine resident files and six employee files were reviewed during the survey.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 6
Facility grade: A
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Feb 26, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but was found deficient in medication administration reviews and infection control training. Specifically, medication reviews were not performed or documented properly for several residents, and the infection control designees lacked required training hours.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to perform six-month medication reviews for 1 of 10 residents (Resident #1). | Level 2 |
| Failed to ensure six-month medication reviews were reviewed and initialed by the Administrator for 6 of 10 residents (Residents #4, #5, #6, #7, #9, and #10). | Level 2 |
| Failed to ensure primary and secondary infection control designees completed the required 15 hours of infection control training. | Level 2 |
Report Facts
Residents reviewed: 10
Employee files reviewed: 5
Medication review deficiencies: 7
Infection control training hours required: 15
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Feb 23, 2023
Visit Reason
The inspection was conducted as an annual and infection control State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several regulatory deficiencies including improper use of full bed rails as restraints, failure to obtain an Alzheimer's endorsement for residents diagnosed with Alzheimer's or dementia, and lack of documented vital signs training for staff.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure full bed rails were not used as restraints, restricting resident mobility. | Level 2 |
| Facility failed to obtain an Alzheimer's endorsement prior to admitting residents diagnosed with Alzheimer's disease or dementia for 4 of 10 residents. | Level 2 |
| Facility failed to ensure vital signs training was completed for 4 of 4 employees performing blood pressure measurements. | Level 2 |
Report Facts
Residents present: 10
Licensed capacity: 10
Residents reviewed: 10
Employee files reviewed: 4
Residents without Alzheimer's endorsement: 4
Employees without vital signs training: 4
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 0
Feb 28, 2022
Visit Reason
The inspection was conducted as an annual State Licensure and Infection Control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and was provided guidance on compliance with certain state regulations related to discrimination, privacy, and cultural competency.
Report Facts
Employee files reviewed: 4
Resident files reviewed: 7
Licensed beds: 10
Current census: 7
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 1
May 4, 2021
Visit Reason
The inspection was conducted as an annual state licensure and infection control survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. One deficiency was identified related to medication storage where the medication cabinet was found unlocked and accessible to residents, which was confirmed by the owner.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication cabinet in the kitchen was unlocked, ajar, and accessible to residents, failing to ensure secure storage of medications. | Severity: 2 |
Report Facts
Census: 10
Total Capacity: 10
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margie Antonio | Administrator | Named as the facility administrator and signatory on the report |
Inspection Report
Abbreviated Survey
Census: 5
Capacity: 10
Deficiencies: 4
Aug 5, 2020
Visit Reason
The inspection was a Focused COVID-19 Infection Control Survey conducted to assess the facility's infection control measures related to the COVID-19 pandemic.
Findings
The facility lacked a written plan for safe and complete infection control measures related to COVID-19. Deficiencies included failure to immediately check the inspector's temperature upon arrival, a caregiver who tested positive for COVID-19 interacting with residents and staff while wearing only a cloth mask, and lack of N95 masks and fit testing for staff.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| The facility lacked written plans for safe and complete infection control measures related to the COVID-19 pandemic. | Severity: 2 |
| The facility did not check the inspector's temperature immediately upon arrival. | Severity: 2 |
| A caregiver who tested positive for COVID-19 was observed walking around the facility interacting with negative residents and staff while wearing a cloth mask. | Severity: 2 |
| Staff were not fit tested and N95 masks were not available. | Severity: 2 |
Report Facts
Surgical masks: 50
Gowns: 6
Pairs of gloves: 440
Hand sanitizer (ounces): 24
Licensed beds: 10
Current residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margie Antonio | Administrator | Named as the Administrator responsible for oversight and implementation of corrective actions |
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 0
Nov 21, 2019
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Report Facts
Licensed beds: 10
Census: 7
Inspection Report
Renewal
Census: 9
Capacity: 10
Deficiencies: 0
May 7, 2019
Visit Reason
This inspection was conducted as a State Licensure re-grading survey for renewal of the facility's license to provide care to elderly and/or disabled residents.
Findings
The facility was found to be in compliance with no deficiencies identified and received a grade of A. The survey included review of resident and employee files and inspection of the premises.
Report Facts
Licensed capacity: 10
Current census: 9
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 19
Jan 15, 2019
Visit Reason
This inspection was a State licensure annual survey conducted to assess compliance with Nevada Administrative Code for a residential facility for groups.
Findings
The facility was found deficient in multiple areas including caregiver training, health and sanitation, kitchen cleanliness, food storage, meal service, resident privacy, bathroom facilities, oxygen equipment, medication administration and documentation, and licensing endorsements. Corrective actions were implemented for all deficiencies.
Severity Breakdown
Level 2: 18
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 employees had training on proper use of Hoyer lift. | Level 2 |
| Medical equipment stored in common sitting area impeding free movement of residents. | Level 2 |
| Facility interior was not clean; dusty window ledges and lamp. | Level 2 |
| Kitchen cabinets above stove were sticky and dusty. | Level 2 |
| Perishable condiments not refrigerated after opening as required. | Level 2 |
| Stored food items were not properly packaged or closed. | Level 2 |
| Meal menus not posted where residents could see and did not include snack times or snacks. | Level 2 |
| Resident with special diet did not receive meals compliant with physician's order. | Level 2 |
| No visual privacy devices in master bedroom shared by 3 residents. | Level 2 |
| Failed to provide at least 24 inches of closet space for 3 residents in master bedroom. | Level 2 |
| Only one functioning tub/shower for eight residents; others covered and not usable. | Level 2 |
| Residents not encouraged to participate in scheduled activities; activities not conducted as posted. | Level 2 |
| No portable oxygen unit available for resident requiring oxygen in event of power outage. | Level 2 |
| Caregivers lacked training on proper operation of oxygen equipment. | Level 2 |
| Failed to obtain waiver/exemption for resident with pressure ulcer. | Level 2 |
| Physician not notified within 12 hours of medication refusal for a resident. | Level 2 |
| Medication refusal documentation incomplete; reason for refusal not recorded in MAR. | Level 2 |
| Prescription medication stored improperly in refrigerator without locked box. | Level 2 |
| Facility failed to acquire Alzheimer's endorsement on license despite caring for residents with dementia. | Level 2 |
Report Facts
Residents present: 8
Total licensed capacity: 10
Deficiencies cited: 18
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 4
Dec 20, 2017
Visit Reason
This inspection was conducted as an annual State licensure survey of the facility to assess compliance with regulatory requirements.
Findings
The facility received a grade of B with deficiencies identified related to personnel files, tuberculosis screening, background checks, medication administration authorizations, and resident tuberculosis testing. The owner and administrator acknowledged the deficiencies and provided plans of correction.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 4 employees met tuberculosis screening requirements. | 2 |
| Failure to ensure 4 of 4 employees met background check requirements. | 2 |
| Failure to ensure 3 of 8 residents signed ultimate user agreements authorizing medication administration. | 2 |
| Failure to ensure 4 of 8 residents met tuberculosis testing requirements. | 2 |
Report Facts
Residents present: 8
Licensed capacity: 10
Employees reviewed: 4
Resident files reviewed: 8
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