Deficiency Records for Twin Lakes Rehabilitation and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Twin Lakes Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-09 | 2023-12-27 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-11-09 | 2023-12-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-09 | 2023-12-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-09 | 2023-12-27 | 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 | 2023-11-09 | 2023-12-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-09 | 2023-12-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-09 | 2023-12-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-09 | 2023-12-27 | 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 | 2023-11-09 | 2023-12-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-09 | 2023-12-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-09 | 2023-12-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-09 | 2023-12-27 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-09 | 2023-12-27 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-09 | 2023-12-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-09 | 2023-12-27 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-13 | 2023-12-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-13 | 2023-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-13 | 2023-12-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-13 | 2023-12-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-11-13 | 2023-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-13 | 2023-12-20 | 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 | 2023-10-03 | 2023-10-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-03 | 2023-10-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-29 | 2023-09-20 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-12 | 2023-08-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-12 | 2023-08-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-12 | 2023-08-10 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-07-12 | 2023-08-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-12 | 2023-08-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-22 | 2023-06-15 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-05-22 | 2023-06-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-07 | 2023-02-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-07 | 2023-02-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-07 | 2023-02-16 | 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 | 2022-12-07 | 2023-02-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-12-07 | 2023-02-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-07 | 2023-02-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-07 | 2023-01-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-07 | 2023-01-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-07 | 2023-01-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-07 | 2023-01-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-07 | 2023-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-07 | 2023-01-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-07 | 2023-01-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-07 | 2023-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-07 | 2023-01-10 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-12-07 | 2023-01-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-07 | 2023-01-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-07 | 2023-01-10 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-12-07 | 2023-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-07 | 2023-01-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-07 | 2023-01-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-07 | 2023-01-10 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-12-07 | 2023-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-07 | 2023-01-10 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-07 | 2023-01-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-07 | 2023-01-10 | 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 | 2022-12-07 | 2023-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-07 | 2023-01-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-07 | 2023-01-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-12-07 | 2023-01-10 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-12-08 | 2022-12-29 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-12-08 | 2022-12-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-12-08 | 2022-12-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-08 | 2022-12-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-12-08 | 2022-12-29 | 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 | 2022-12-08 | 2022-12-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-08 | 2022-12-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-08 | 2022-12-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-08 | 2022-12-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-08 | 2022-12-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-08 | 2022-12-29 | 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 | 2022-10-03 | 2022-11-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-03 | 2022-11-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-15 | 2022-11-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-15 | 2022-11-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-07-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-26 | 2022-07-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-05 | 2022-06-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-24 | 2022-02-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-06 | 2022-02-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-02-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-12 | 2022-02-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-12 | 2022-02-18 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-01-12 | 2022-02-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-12 | 2022-02-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-12 | 2022-02-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-01-12 | 2022-02-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-12 | 2022-02-18 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-01-12 | 2022-02-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-01-12 | 2022-02-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-12 | 2022-02-18 | N |
| Meet other general requirements. | Fire Safety | 2022-01-12 | 2022-02-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-01-12 | 2022-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-12 | 2022-02-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-07 | 2022-02-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-07 | 2022-02-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-06 | 2021-09-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-06 | 2021-09-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-06 | 2021-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-09-09 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-06 | 2021-09-09 | Y |
