Deficiency Records for Twin Oaks Center
Updated as of February 01, 2022
This is not the most recent data for Twin Oaks Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2020-08-10 | 2020-08-28 | 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 |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Meet other general requirements. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-14 | 2018-09-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-18 | 2018-08-24 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-07-18 | 2018-08-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-07-18 | 2018-08-24 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-07-18 | 2018-08-24 | N |
| Maintain 15 months of resident assessments in the resident's active clinical record. | Health | 2018-07-18 | 2018-08-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-18 | 2018-08-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-18 | 2018-08-24 | 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 | 2018-07-18 | 2018-08-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-07-18 | 2018-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-18 | 2018-08-24 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2018-07-18 | 2018-08-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-04-28 | 2017-06-05 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-04-28 | 2017-06-05 | N |
| Provide clean bed and bath linens that are in good condition. | Health | 2017-04-28 | 2017-06-05 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-04-28 | 2017-06-05 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-04-28 | 2017-06-05 | N |
| Give or get specialized rehabilitative services per the patient's assessment or plan of care. | Health | 2017-04-28 | 2017-06-05 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-28 | 2017-06-05 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-28 | 2017-06-05 | N |
