A list of the most recent deficiencies for Twin Pines Adult Care 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-30 | 2023-03-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-30 | 2023-03-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-30 | 2023-03-16 | 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 | 2023-01-30 | 2023-03-16 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-01-30 | 2023-03-16 | N |
| Post nurse staffing information every day. | Health | 2023-01-30 | 2023-03-16 | 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 | 2023-01-30 | 2023-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-30 | 2023-03-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-30 | 2023-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-30 | 2023-03-16 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Meet other general requirements. | Fire Safety | 2023-01-30 | 2023-03-16 | 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 | 2023-01-30 | 2023-03-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-30 | 2023-03-16 | N |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2021-04-07 | 2021-05-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-07 | 2021-05-11 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-07 | 2021-05-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-07 | 2021-05-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-07 | 2021-05-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-07 | 2021-05-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-07 | 2021-05-11 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-07 | 2019-12-07 | 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 | 2019-06-07 | 2019-07-17 | 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 | 2019-06-07 | 2019-07-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-07 | 2019-07-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-07 | 2019-07-17 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-07 | 2019-07-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-07 | 2019-07-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-07 | 2019-07-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-07 | 2019-07-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-07 | 2019-07-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-07 | 2019-07-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-07 | 2019-07-17 | 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 | 2019-06-07 | 2019-07-17 | 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 | 2019-06-07 | 2019-07-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-07 | 2019-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-07 | 2019-07-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-07 | 2019-07-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-07 | 2019-07-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-07 | 2019-07-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-02 | 2018-06-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-02 | 2018-06-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-02 | 2018-06-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-05-02 | 2018-06-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-02 | 2018-06-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-05-02 | 2018-06-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-02 | 2018-06-19 | N |
