A list of the most recent deficiencies for Twin Oaks 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? |
|---|---|---|---|---|
| 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 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 |
| Observe each nurse aide's job performance and give regular training. | 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 |
| 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 |
| 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 |
| 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-03 | 2023-06-09 | N |
| Provide activities to meet all resident's needs. | 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 appropriate foot care. | 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 safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-03 | 2023-06-09 | N |
| Provide or obtain dental services for each resident. | Health | 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 |
| 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 | 2023-05-18 | 2023-06-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-18 | 2023-06-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-18 | 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 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 |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-03 | 2023-05-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-01 | 2023-02-22 | Y |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-03-24 | 2022-04-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-24 | 2022-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-24 | 2022-04-11 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-03-10 | 2022-04-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-10 | 2022-04-08 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-10 | 2022-04-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-10 | 2022-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-10 | 2022-04-08 | 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 | 2022-03-10 | 2022-04-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-10 | 2022-04-08 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-03-10 | 2022-04-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-03-10 | 2022-04-08 | 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 | 2022-03-10 | 2022-04-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-10 | 2022-04-08 | N |
| Dispose of garbage and refuse properly. | Health | 2022-03-10 | 2022-04-08 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-08-09 | 2019-11-04 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-08-09 | 2019-11-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-09 | 2019-09-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-04 | 2019-07-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-06-04 | 2019-07-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-06-04 | 2019-07-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-04 | 2019-07-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-04 | 2019-07-13 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-04 | 2019-07-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-04 | 2019-07-13 | 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 | 2019-06-04 | 2019-07-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-04 | 2019-07-13 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-06-04 | 2019-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-04 | 2019-07-13 | 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 | 2019-06-04 | 2019-07-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-04 | 2019-07-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-06-04 | 2019-07-13 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-04 | 2019-07-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-04 | 2019-07-13 | 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 | 2019-06-04 | 2019-07-13 | 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 | 2019-06-04 | 2019-07-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-06-04 | 2019-07-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-06-04 | 2019-07-13 | 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 | 2019-06-04 | 2019-07-13 | 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 | 2019-06-04 | 2019-07-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-04 | 2019-07-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-04 | 2019-07-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-06-04 | 2019-07-13 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-06-04 | 2019-07-13 | 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 | 2019-06-04 | 2019-07-13 | 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 | 2019-06-04 | 2019-06-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-04 | 2019-06-04 | N |
