A list of the most recent deficiencies for Twilight Haven. 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? |
|---|---|---|---|---|
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-03-17 | 2023-03-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-26 | 2023-03-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-22 | 2022-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-22 | 2022-08-29 | N |
| Provide appropriate foot care. | Health | 2022-07-22 | 2022-08-29 | 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 | 2022-07-22 | 2022-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-22 | 2022-08-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-22 | 2022-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-22 | 2022-08-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-22 | 2022-08-29 | N |
| 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. | Health | 2022-07-22 | 2022-08-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-22 | 2022-08-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-07-26 | 2022-08-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-29 | 2019-12-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-29 | 2019-12-31 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-29 | 2019-12-31 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-08-29 | 2019-12-31 | N |
| Dispose of garbage and refuse properly. | Health | 2019-08-29 | 2019-12-31 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-08-29 | 2019-12-31 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-08-29 | 2019-12-31 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-08-29 | 2019-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-29 | 2019-12-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-01 | 2019-11-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-01 | 2019-11-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-01 | 2019-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-01 | 2019-11-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-01 | 2019-11-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Develop a communication plan. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-03 | 2019-02-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-03 | 2019-02-05 | 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 | 2018-09-27 | 2018-10-22 | 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 | 2018-09-27 | 2018-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-27 | 2018-10-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-09-27 | 2018-10-22 | N |
