Deficiency Records for Twinbrook Healthcare and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Twinbrook Healthcare and Rehabilitation 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 emergency prep training and testing. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-13 | 2023-08-02 | 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 | 2023-06-13 | 2023-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-13 | 2023-08-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-08 | 2023-07-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-08 | 2023-07-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-08 | 2023-07-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-07-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-08 | 2023-07-25 | N |
| 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 | 2023-06-08 | 2023-07-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-07-25 | 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 | 2023-06-08 | 2023-07-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-27 | 2023-03-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-27 | 2023-03-08 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-19 | 2022-09-02 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-07-15 | 2022-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-15 | 2022-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-15 | 2022-08-10 | 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 | 2022-07-15 | 2022-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-15 | 2022-08-10 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-07-15 | 2022-08-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-15 | 2022-08-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-15 | 2022-08-10 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-21 | 2022-01-23 | N |
| Meet other general requirements. | Fire Safety | 2021-09-21 | 2022-01-23 | N |
| Use approved construction type or materials. | Fire Safety | 2021-09-21 | 2022-01-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-21 | 2022-01-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-21 | 2022-01-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-09-21 | 2022-01-23 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-21 | 2021-11-20 | 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 | 2021-09-21 | 2021-11-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-09-21 | 2021-11-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-17 | 2021-10-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-17 | 2021-10-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-17 | 2021-10-19 | 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 | 2021-09-17 | 2021-10-19 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-09-17 | 2021-10-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-17 | 2021-10-19 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-09-17 | 2021-10-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-16 | 2021-09-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-16 | 2021-09-08 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-07-16 | 2021-09-08 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-05 | Not Fixed | Y |
