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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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