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 |