All citations for Twinbrook Healthcare and Rehabilitation Center

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Twinbrook Healthcare and Rehabilitation Center

Last standard health inspection on record

April 16, 2026

Showing 26 to 50 of 57 citations

  1. No harm, with potential for more than minimal harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of April 16, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  2. No harm, with potential for more than minimal harm

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0698, Quality of Life and Care Deficiencies. Inspection of April 16, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  3. No harm, with potential for more than minimal harm

    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0711, Nursing and Physician Services Deficiencies. Inspection of April 16, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  4. No harm, with potential for more than minimal harm

    Ensure that the resident and his/her doctor meet face-to-face at all required visits.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0712, Nursing and Physician Services Deficiencies. Inspection of April 16, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  5. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of April 16, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  6. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of April 16, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 8, 2026).

  7. No harm, with potential for more than minimal harm

    Have proper medical gas storage and administration areas.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 16, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 8, 2026).

  8. No harm, with potential for more than minimal harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0580, Resident Rights Deficiencies. Inspection of March 10, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 8, 2026).

  9. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0578, Resident Rights Deficiencies. Inspection of April 25, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 30, 2025).

  10. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of April 25, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 30, 2025).

  11. No harm, with potential for more than minimal harm

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    Isolated (one or a few residents). CMS level D.

    Health citation F-0655, Resident Assessment and Care Planning Deficiencies. Inspection of April 25, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 30, 2025).

  12. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of April 25, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 30, 2025).

  13. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0688, Quality of Life and Care Deficiencies. Inspection of April 25, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 30, 2025).

  14. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0727, Nursing and Physician Services Deficiencies. Inspection of April 25, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (May 30, 2025).

  15. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of April 25, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 30, 2025).

  16. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of December 23, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 20, 2025).

  17. No harm, with potential for more than minimal harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of May 17, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 2, 2024).

  18. No harm, with potential for more than minimal harm

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    Isolated (one or a few residents). CMS level D.

    Health citation F-0655, Resident Assessment and Care Planning Deficiencies. Inspection of May 17, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 2, 2024).

  19. No harm, with potential for more than minimal harm

    Provide safe, appropriate pain management for a resident who requires such services.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of May 17, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 2, 2024).

  20. No harm, with potential for more than minimal harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of May 17, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 2, 2024).

  21. No harm, with potential for more than minimal harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0756, Pharmacy Service Deficiencies. Inspection of May 17, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 2, 2024).

  22. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of May 17, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 14, 2024).

  23. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of May 17, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 14, 2024).

  24. No harm, with potential for minimal harm

    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.

    Widespread (many residents). CMS level C.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of February 12, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 20, 2026).

  25. No harm, with potential for minimal harm

    Post nurse staffing information every day.

    Widespread (many residents). CMS level C.

    Health citation F-0732, Nursing and Physician Services Deficiencies. Inspection of February 12, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (March 20, 2026).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.