Provider Name: TRANQUILITY NURSING AND REHAB
Address: 3640 N CENTRAL AVENUE, INDIANAPOLIS, IN 46205
Phone: (317) 744-0364
County: Marion (480)
Ownership Type: Government - County
Certified Beds: 78
Average Residents Per Day: 31.1 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: PULASKI MEMORIAL HOSPITAL
First Approved Date: June 1, 2019
Affiliated Entity: PULASKI MEMORIAL HOSPITAL (435)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 1 ()
Health Inspection Rating: 1 ()
QM Rating: 1 ()
Long Stay QM Rating: 1 ()
Short Stay QM Rating: (2)
Staffing Rating: 1 (12)
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 0.74363, LPN Staff Hours Per Day: 0.0000, RN Staff Hours Per Day: 0.0000, Licensed Staff Hours Per Day: 0.0000
Total Nurse Staff Hours Per Day, per resident: 0.74363
Weekend Nurse Staff Hours: 0.83227, Weekend RN Staff Hours: 0.0000
PT Staff Hours Per Day, per resident: 0.0000
Nurse Staff Turnover: , Nurse Turnover Note: 6
RN Turnover: , RN Turnover Note: 6
Admin Left Number: , Admin Turnover Note: 6
Case Mix Nurse Aide Hours Per Day, per resident: 2.0328, Case Mix LPN Hours Per Day: 0.8627, Case Mix RN Hours Per Day: 0.7513
Adjusted Nurse Aide Hours Per Day, per resident: 0.74524, Adjusted LPN Hours Per Day: 0.0000, Adjusted RN Hours Per Day: 0.0000
Total Adjusted Nurse Hours Per Day, per resident: 0.64271
Adjusted Weekend Nurse Hours Per Day, per resident: 0.71933
Health Survey Dates and Scores: Cycle 1: 2023-06-15 (Score: 68), Cycle 2: 2021-08-19 (Score: 104), Cycle 3: 2019-05-31 (Score: 60)
Total Weighted Health Score: 96.000
Reported Incidents: 0, Substantiated Complaints: 12
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 14, Total Fines in Dollars: 80690.21, Payment Denials Number: 1, Total Penalties Number: 15
Location and GPS: 3640 N CENTRAL AVENUE,INDIANAPOLIS,IN,46205 (39.8221, -86.150)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-25
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-25
Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-25
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-04
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-04
Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-04
Type: Health, Deficiency: Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-04
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: Provide timely, quality laboratory services/tests to meet the needs of residents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-15
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: The resident has the right to receive notices in a format and a language he or she understands.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-11
Type: Health, Deficiency: Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-11
Type: Health, Deficiency: Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-11
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-11
Type: Health, Deficiency: Report COVID19 data to residents and families.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Perform COVID19 testing on residents and staff.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-11
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-22
Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-25
Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-01-25
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-29
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-11
Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-11
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-29
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-08
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-11-11
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-05-24
Type: Health, Deficiency: Ensure that residents are free from significant medication errors.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-05-24
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0037, Version: New
Description: Establish staff and initial training requirements.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-01
Type: Fire Safety, Tag: 0041, Version: New
Description: Implement emergency and standby power systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-01
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-01
Type: Fire Safety, Tag: 0351, Version: New
Description: Install an approved automatic sprinkler system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-01
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-01
Type: Fire Safety, Tag: 0500, Version: New
Description: Meet other general requirements that are deficient.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-01
Type: Fire Safety, Tag: 0712, Version: New
Description: Have simulated fire drills held at unexpected times.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-01
Type: Fire Safety, Tag: 0907, Version: New
Description: Ensure medical gas and vacuum systems have documented maintenance programs.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2023-09-07
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-01
Type: Fire Safety, Tag: 0031, Version: New
Description: Provide emergency officials' contact information.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0037, Version: New
Description: Establish staff and initial training requirements.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0324, Version: New
Description: Provide properly protected cooking facilities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0346, Version: New
Description: Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0354, Version: New
Description: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0362, Version: New
Description: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0372, Version: New
Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0914, Version: New
Description: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-10-04
Type: Fire Safety, Tag: 0031, Version: New
Description: Provide emergency officials' contact information.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0100, Version: New
Description: Meet other general requirements.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0324, Version: New
Description: Provide properly protected cooking facilities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0331, Version: New
Description: Construct fire resistant interior walls.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0346, Version: New
Description: Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0354, Version: New
Description: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0372, Version: New
Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0500, Version: New
Description: Meet other general requirements that are deficient.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0904, Version: New
Description: Have a properly installed medical gas master alarm panel.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-18
Type: Fire Safety, Tag: 0911, Version: New
Description: Meet requirements for the installation and maintenance of electrical systems.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-19