Deficiency Records for Twilight Gardens Nursing and Rehabilitation
Updated as of April 01, 2021
This is not the most recent data for Twilight Gardens Nursing and Rehabilitation. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Report COVID19 data to residents and families. | Health | 2021-01-06 | 2021-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-22 | 2020-11-20 | Y |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2020-09-03 | 2020-09-18 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-09-03 | 2020-09-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-05 | 2019-12-12 | Y |
| 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 |
| 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 | Y |
| 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 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-07 | 2019-03-15 | Y |
| 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 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-15 | Y |
| 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 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-16 | 2018-04-17 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-01-18 | 2018-02-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-01-18 | 2018-02-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-18 | 2018-02-06 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-01-18 | 2018-02-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-01-18 | 2018-02-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-01-18 | 2018-02-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-18 | 2018-02-06 | 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 | 2018-01-18 | 2018-02-06 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-01-18 | 2018-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-18 | 2018-02-06 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-10-17 | 2016-11-04 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-10-17 | 2016-11-04 | N |
| Properly maintained smoke detectors. | Fire Safety | 2016-10-17 | 2016-11-04 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-10-17 | 2016-11-04 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-10-17 | 2016-11-04 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-10-20 | 2016-11-04 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-10-20 | 2016-11-04 | N |
