Deficiency Records for Twin Lakes Rehabilitation and Healthcare Center
Updated as of May 01, 2020
This is not the most recent data for Twin Lakes Rehabilitation and Healthcare Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 | 2019-12-03 | 2019-12-18 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-10-24 | 2019-12-03 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-24 | 2019-12-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2019-12-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-18 | 2019-12-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-18 | 2019-12-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-18 | 2019-12-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-18 | 2019-12-03 | 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 | 2019-10-18 | 2019-12-03 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-18 | 2019-12-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-18 | 2019-12-03 | 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 ne | Health | 2019-10-18 | 2019-12-03 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-18 | 2019-12-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-18 | 2019-12-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-18 | 2019-12-03 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-18 | 2019-12-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-17 | 2019-12-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-17 | 2019-12-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-08 | 2019-12-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-08 | 2019-12-03 | 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 | 2019-08-08 | 2019-12-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-08 | 2019-12-03 | 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 ne | Health | 2019-08-08 | 2019-12-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-08 | 2019-12-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-08 | 2019-12-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-08-08 | 2019-12-03 | 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 | 2019-08-08 | 2019-11-06 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2019-08-08 | 2019-11-06 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2019-08-08 | 2019-11-06 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2019-08-08 | 2019-11-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-08-08 | 2019-09-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-08 | 2019-09-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-08 | 2019-09-19 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-08-08 | 2019-09-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-08 | 2019-09-19 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-08-08 | 2019-09-19 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-08-08 | 2019-09-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-08 | 2019-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-08 | 2019-09-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-08 | 2019-09-19 | 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 | 2019-08-08 | 2019-09-19 | 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 | 2019-08-08 | 2019-09-19 | 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 | 2019-08-08 | 2019-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-08 | 2019-09-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-08 | 2019-09-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-08-08 | 2019-09-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-07-17 | 2019-08-27 | 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 | 2019-07-17 | 2019-08-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-17 | 2019-08-27 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-07-17 | 2019-08-27 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2019-05-17 | 2019-06-14 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-03-29 | 2019-04-22 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-03-29 | 2019-04-22 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2019-03-29 | 2019-04-22 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-14 | 2019-04-15 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-02-14 | 2019-04-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-13 | 2019-03-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-13 | 2019-03-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-13 | 2019-03-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-13 | 2019-03-28 | 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 | 2019-02-13 | 2019-03-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-13 | 2019-03-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-02-13 | 2019-03-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-13 | 2019-03-28 | 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 | 2019-02-13 | 2019-03-28 | 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 | 2019-02-13 | 2019-03-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-13 | 2019-03-28 | 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 | 2019-02-13 | 2019-03-28 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-02-13 | 2019-03-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-13 | 2019-03-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-13 | 2019-03-28 | 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 | 2019-02-13 | 2019-03-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-13 | 2019-03-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-02-13 | 2019-03-28 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-02-13 | 2019-03-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-13 | 2019-03-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-02-13 | 2019-03-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-13 | 2019-03-28 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-02-13 | 2019-03-28 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-02-13 | 2019-03-28 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Meet other general requirements. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-14 | 2019-03-15 | 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 | 2019-02-14 | 2019-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-10 | 2018-11-03 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2018-10-10 | 2018-11-03 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-10-10 | 2018-11-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-01 | 2018-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-01 | 2018-10-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-10-01 | 2018-10-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-17 | 2018-09-06 | 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 | 2018-08-17 | 2018-09-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-08-17 | 2018-09-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-17 | 2018-09-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-17 | 2018-09-06 | Y |
| 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 | 2018-08-17 | 2018-09-06 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-08-17 | 2018-09-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-08-17 | 2018-09-06 | 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 | 2018-07-19 | 2018-09-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-19 | 2018-09-06 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-07-19 | 2018-09-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-11 | 2018-09-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-05-11 | 2018-09-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-19 | 2018-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-11 | 2018-08-01 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-05-15 | 2018-06-29 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-05-15 | 2018-06-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-05-15 | 2018-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-15 | 2018-06-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-15 | 2018-06-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-15 | 2018-06-29 | N |
| Post nurse staffing information every day. | Health | 2018-05-11 | 2018-06-29 | 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 | 2018-05-11 | 2018-06-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-05-11 | 2018-06-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-11 | 2018-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-11 | 2018-06-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-11 | 2018-06-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-05-11 | 2018-06-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-11 | 2018-06-22 | 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 | 2018-05-11 | 2018-06-22 | 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 | 2018-05-11 | 2018-06-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-11 | 2018-06-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-11 | 2018-06-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-05-11 | 2018-06-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-05-11 | 2018-06-22 | Y |
| Provide activities to meet all resident's needs. | Health | 2018-05-11 | 2018-06-22 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-02-02 | 2018-02-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-12-26 | 2018-01-26 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2017-12-26 | 2018-01-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2017-12-26 | 2018-01-26 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2017-11-30 | 2017-12-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2017-11-30 | 2017-12-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2017-11-30 | 2017-12-30 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-28 | 2017-08-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-07-28 | 2017-08-16 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-28 | 2017-08-16 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-07-28 | 2017-08-16 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-07-28 | 2017-08-16 | Y |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-07-28 | 2017-08-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-28 | 2017-08-16 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-07-28 | 2017-08-16 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-07-28 | 2017-08-16 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-07-28 | 2017-08-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-07-28 | 2017-08-16 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-07-28 | 2017-08-16 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-07-28 | 2017-08-16 | Y |
