A list of the most recent deficiencies for Twin Willows Nursing 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? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-02-07 | 2024-03-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-02-07 | 2024-03-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-02-07 | 2024-03-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-07 | 2024-03-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-07 | 2024-03-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-02-07 | 2024-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-07 | 2024-03-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-02-07 | 2024-03-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-01-05 | 2024-01-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-05 | 2024-01-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-15 | 2023-02-28 | 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 | 2022-12-15 | 2023-02-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-14 | 2023-02-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-14 | 2023-01-27 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-12-14 | 2023-01-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-14 | 2023-01-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-02 | 2021-12-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-04 | 2021-11-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-04 | 2021-11-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-04 | 2021-11-30 | 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 | 2021-11-04 | 2021-11-30 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-04 | 2021-11-30 | N |
