A list of the most recent deficiencies for Twin Oaks Health and Rehab. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-24 | 2023-07-17 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-04-10 | 2023-05-04 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-10 | 2023-05-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-10 | 2023-05-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-10 | 2023-05-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-23 | 2023-04-08 | 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 | 2023-02-23 | 2023-04-08 | 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 | 2023-02-23 | 2023-04-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-23 | 2023-04-08 | 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 | 2021-08-23 | 2021-09-23 | 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 | 2021-08-23 | 2021-09-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-23 | 2021-09-23 | 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 | 2021-08-23 | 2021-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-23 | 2021-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-23 | 2021-09-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-20 | 2021-09-20 | 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 | 2021-08-20 | 2021-09-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-20 | 2021-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-20 | 2021-09-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-20 | 2021-09-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-20 | 2021-09-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-20 | 2021-09-20 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
