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Deficiency Records for Twinbrook Healthcare and Rehabilitation Center
A list of the most recent deficiencies for Twinbrook Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Twinbrook Healthcare and Rehabilitation Center. 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? |
---|---|---|---|---|
Meet other general requirements. | Fire Safety | 2024-05-15 | 2024-07-14 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-05-15 | 2024-07-14 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-15 | 2024-07-14 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-15 | 2024-07-14 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-15 | 2024-07-14 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-17 | 2024-07-02 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-17 | 2024-07-02 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-17 | 2024-07-02 | 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 | 2024-05-17 | 2024-07-02 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-17 | 2024-07-02 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-05-17 | 2024-07-02 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-17 | 2024-07-02 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-05-17 | 2024-07-02 | N |
Establish emergency prep training and testing. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
Install a two-hour-resistant firewall separation. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-08 | 2023-07-25 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-08 | 2023-07-25 | N |
Ensure each resident receives an accurate assessment. | Health | 2023-06-08 | 2023-07-25 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-07-25 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-08 | 2023-07-25 | 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 | 2023-06-08 | 2023-07-25 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-07-25 | 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 | 2023-06-08 | 2023-07-25 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-27 | 2023-03-08 | Y |
Ensure that residents are free from significant medication errors. | Health | 2023-01-27 | 2023-03-08 | Y |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
Provide properly protected cooking facilities. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-07-15 | 2022-08-10 | N |
Ensure each resident receives an accurate assessment. | Health | 2022-07-15 | 2022-08-10 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-15 | 2022-08-10 | 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 | 2022-07-15 | 2022-08-10 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-15 | 2022-08-10 | N |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-07-15 | 2022-08-10 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-15 | 2022-08-10 | N |
Provide and implement an infection prevention and control program. | Health | 2022-07-15 | 2022-08-10 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-05 | Not Fixed | Y |
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