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Deficiency Records for Twin Oaks Center
View the most recent health deficiencies and inspection results for Twin Oaks Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Twin Oaks Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-06-18 | 2025-08-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-06-18 | 2025-08-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2025-06-18 | 2025-08-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2025-06-18 | 2025-08-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-06-18 | 2025-08-10 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2025-06-18 | 2025-08-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2025-06-18 | 2025-08-10 | 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 | 2025-06-18 | 2025-08-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-06-18 | 2025-08-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2025-06-18 | 2025-08-10 | N |
| Develop a communication plan. | Fire Safety | 2025-06-18 | 2025-08-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-06-18 | 2025-08-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-06-18 | 2025-07-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-06-18 | 2025-07-24 | 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 | 2025-06-18 | 2025-07-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-06-18 | 2025-07-24 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2025-06-18 | 2025-07-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-06-18 | 2025-07-24 | 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 | 2025-06-18 | 2025-07-24 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2025-06-18 | 2025-07-24 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2025-06-18 | 2025-07-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-06-18 | 2025-07-24 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-06-18 | 2025-07-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-06-18 | 2025-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-06-18 | 2025-07-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2025-06-18 | 2025-07-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-06-18 | 2025-07-24 | 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 | 2025-06-18 | 2025-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-06-18 | 2025-07-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-06-18 | 2025-07-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-06-18 | 2025-07-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-06-18 | 2025-07-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-06-18 | 2025-07-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-11 | 2024-08-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-11 | 2024-07-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-11 | 2024-07-11 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-07-11 | 2024-07-11 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-12-12 | 2024-01-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-03 | 2023-06-27 | 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 | 2023-05-03 | 2023-06-27 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-03 | 2023-06-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-03 | 2023-06-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-03 | 2023-06-16 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-03 | 2023-06-16 | 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 | 2023-05-03 | 2023-06-12 | 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 | 2023-05-03 | 2023-06-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-03 | 2023-06-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-03 | 2023-06-09 | N |
| Provide or obtain dental services for each resident. | Health | 2023-05-03 | 2023-06-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-03 | 2023-06-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-03 | 2023-06-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-03 | 2023-06-09 | N |
| Provide appropriate foot care. | Health | 2023-05-03 | 2023-06-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-03 | 2023-06-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-03 | 2023-06-09 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-03 | 2023-06-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-03 | 2023-06-09 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-03 | 2023-06-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-05-03 | 2023-06-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-05-03 | 2023-06-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-03 | 2023-06-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-03 | 2023-06-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-03 | 2023-06-09 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-03 | 2023-06-09 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-03 | 2023-06-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-03 | 2023-06-02 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-03 | 2023-06-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-03 | 2023-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-03 | 2023-05-29 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-03 | 2023-05-15 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-03 | 2023-05-09 | 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 | 2023-05-03 | 2023-05-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-03 | 2023-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-05-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-03 | 2023-05-03 | 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 | 2023-05-03 | 2023-05-03 | N |