A list of the most recent deficiencies for Twin Lakes Rehab and Health Care. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-14 | 2024-01-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-14 | 2024-01-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-14 | 2024-01-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-14 | 2024-01-10 | Y |
| 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 | 2023-12-14 | 2024-01-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-25 | 2023-10-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-25 | 2023-10-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-22 | 2023-08-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-22 | 2023-08-25 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-17 | 2023-06-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-17 | 2023-06-10 | N |
| Develop a communication plan. | Fire Safety | 2023-05-17 | 2023-06-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-17 | 2023-06-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-17 | 2023-06-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-17 | 2023-06-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-17 | 2023-06-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-17 | 2023-06-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-18 | 2023-06-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-18 | 2023-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-18 | 2023-06-01 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-05-18 | 2023-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-18 | 2023-05-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-05-18 | 2023-05-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-18 | 2022-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-08 | 2022-07-05 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-06-08 | 2022-07-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-17 | 2022-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-17 | 2022-06-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-17 | 2022-06-01 | N |
| 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. | Health | 2022-05-17 | 2022-06-01 | 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 | 2022-05-17 | 2022-06-01 | N |
| Post nurse staffing information every day. | Health | 2022-05-17 | 2022-06-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-17 | 2022-06-01 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-05-17 | 2022-06-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-17 | 2022-06-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-17 | 2022-06-01 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2022-05-17 | 2022-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-05 | 2021-09-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-05 | 2021-06-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-05 | 2021-05-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-05 | 2021-05-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-05 | 2021-05-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-05 | 2021-05-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-23 | 2021-05-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-23 | 2021-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-23 | 2021-05-10 | 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 | 2021-04-23 | 2021-05-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-23 | 2021-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-23 | 2021-05-10 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-04-23 | 2021-05-10 | N |
