Deficiency Records for Twin Willows Nursing Center
Updated as of June 01, 2022
This is not the most recent data for Twin Willows Nursing Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Develop a communication plan. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-10 | 2020-03-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-02-07 | 2020-02-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-07 | 2020-02-27 | N |
| Provide or obtain dental services for each resident. | Health | 2020-02-07 | 2020-02-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-07 | 2020-02-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-10 | 2020-02-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-10 | 2020-02-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-03-27 | 2019-05-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-03-29 | 2019-05-01 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-03-29 | 2019-05-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-29 | 2019-05-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-03-29 | 2019-05-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-03-29 | 2019-05-01 | 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 | 2019-03-29 | 2019-05-01 | 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 | 2019-03-27 | 2019-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-27 | 2019-05-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-27 | 2019-04-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-03-27 | 2019-03-29 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2019-03-27 | 2019-03-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-27 | 2019-03-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-03-27 | 2019-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-27 | 2019-03-27 | N |
