Deficiency Records for Twilight Gardens Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Twilight Gardens Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-19 | 2023-12-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-19 | 2023-12-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-19 | 2023-12-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-19 | 2023-12-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-19 | 2023-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-12-07 | 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 | 2023-10-17 | 2023-12-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-17 | 2023-12-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-17 | 2023-12-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-17 | 2023-12-07 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-10-17 | 2023-12-07 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-14 | 2023-06-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-14 | 2022-11-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-12 | 2022-05-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-12 | 2022-05-13 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-04-29 | 2022-05-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-29 | 2022-05-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-29 | 2022-05-13 | Y |
| 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 | 2022-04-29 | 2022-05-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-07 | 2022-05-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-07 | 2022-05-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-07 | 2022-02-04 | Y |
| 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 | 2021-12-13 | 2022-02-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-04 | 2021-12-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-04 | 2021-12-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-04 | 2021-12-01 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-22 | 2021-07-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-22 | 2021-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-22 | 2021-07-21 | 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 | 2021-06-21 | 2021-07-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-21 | 2021-07-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-21 | 2021-07-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-21 | 2021-07-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-21 | 2021-07-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-21 | 2021-07-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-21 | 2021-07-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-21 | 2021-07-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-18 | 2021-06-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-18 | 2021-06-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-03 | 2021-03-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-03 | 2021-03-24 | Y |
| 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 | 2021-03-03 | 2021-03-24 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-03-03 | 2021-03-24 | Y |
| 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 | 2019-02-07 | 2019-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-07 | 2019-03-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-07 | 2019-03-15 | 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 | 2019-02-07 | 2019-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-02-07 | 2019-03-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
