Twin Oaks Center

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure it provided appropriate administrative oversight in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to ensure pre-employment health requirements and dementia training was provided to all staff to provide competent, safe, and effective resident care as well as ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in leadership and staffing. Specifically, the facility administration failed to: 1. Ensure effective systems were in place for education, and training for licensed staff to ensure competent, and safe practice. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the governing body provided oversight and accountability for: 1. The maintenance of an effective QAPI program. 2. The provision of an infection control/antibiotic stewardship program.

Inspectors wroteBased on interview and document review, the facility failed to implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility developed QAPI plans related to staff education and infection control once these concerns were identified by the Administrator.

Inspectors wroteBased on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee met quarterly, identified quality deficient areas to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes. Findings Include: Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated January 2025, indicated the following: -Purpose: To ensure the delivery of the highest standard of care and services to our residents. Our QAPI program is designed to monitor, assess, and continuously improve all aspects of care and operations, addressing areas for improvement proactively, and ensuring that quality outcomes are consistently achieved. - Program Overview: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting of infections, communicable diseases and outbreaks among residents and staff.

Inspectors wroteBased on record review and interviews, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics.

Inspectors wroteBased on observations and interviews, the facility failed to ensure 1.) a medication cart was locked when unattended, on one of three nursing units, 2.) medications were labeled, and dated once opened, according to manufacturer's guidelines on one out of three medication carts sampled, 3.) store medications at proper temperatures and other appropriate environmental controls to preserve their integrity.

Inspectors wroteBased on observations and interviews the facility failed to ensure a dignified dining experience on one out of three units. Specifically on the 1st floor unit, dining room staff failed to provide dignified dining experience and referred to residents as feeders, rather than by their name.

Inspectors wroteBased on record review and interview, the facility failed to 1.) report a fall, resulting in a head laceration requiring staples and, 2.) report a fall, resulting in a fracture of the right femoral neck (right thigh bone) requiring surgery, to the state agency as required for one Resident (#42), out of a total sample of 21 residents.

Inspectors wroteBased on record review and interviews, the facility failed to develop a person-centered behavior care plan for one Resident (#10) out of a total sample of 21 residents. Specifically, the facility failed to develop a person-centered care plan for a history of chronic paranoia and delusions.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide Nursing services consistent with professional standards of practice for two Residents #24 and #11 out of a total sample of 21 residents. Specifically; 1. For Resident # 24, the facility failed to include how much oxygen the Resident should be taking via nasal cannula, and how often the oxygen tubing should be changed in the physician's orders. 2. For Resident #11, the facility failed to implement a physician's order to administer tube feeding with correct enteral feeding and correct rate.

Inspectors wroteBased on observation, record review and interview the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#56) out of a total sample of 21 residents. Specifically; the facility failed to change a wound dressing for three days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#11) out of a total sample of 21 residents. Specifically, the facility failed to ensure staff implemented Resident #11's, physician ordered, rolled facecloth to contracted [left] hand every shift.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#1) out of a total sample of 21 residents. Specifically, for Resident #1 the facility failed to ensure significant weigh loss was assessed and continually monitored.

Inspectors wroteBased on record review and interviews, the facility failed to develop a trauma informed care plan for two Residents #10 and #1 out of a total sample of 21 residents. Specifically: 1. For Resident #10, the facility failed to develop a post-traumatic stress disorder (PTSD) care plan addressing the needs of trauma by minimizing triggers and re-traumatization. 2. For Resident #1, the facility failed to develop a care plan addressing PTSD with a history of suicide attempt.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Specifically, one of two nurses observed made two errors in 33 opportunities resulting in a medication error rate of 6.06%. These errors impacted one Resident (#18) out of four residents observed.

Inspectors wroteBased on observation, record review and interviews, the facility failed to accurately document in the medical record for one Resident (#56 ) out of a total sample of 21 residents. Specifically, for Resident #56 the facility documented a dressing change was completed for three days when it was not.

Inspectors wroteBased on record review and interviews, the facility failed to offer the Influenza vaccine during influenza season to one Resident out of a sample of five residents reviewed. Specifically, the facility failed to offer Influenza vaccination on admission to the facility or during their stay at the facility.

Inspectors wroteBased on record review and interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine to one out of five sampled residents. Specifically, the facility failed to offer a COVID-19 vaccination to a resident on admission to the facility or during their stay at the facility.

Inspectors wroteBased on record review and interview, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#37) out of a total sample of 18 residents. Specifically, the facility failed to provide adequate hydration for a Resident who requires assistance to full dependence for eating and drinking, resulting in a hospitalization due to dehydration, an acute kidney injury, and hypernatremia.

Inspectors wroteBased on record review and interview, the facility failed to promptly notify the physician/ nurse practitioner (NP) of a critically high sodium lab for one Resident (#37), out of a total sample of 18 residents.

Inspectors wroteBased on record review and interview the facility failed to meet professional standards of quality for four Residents (#55, #48, #63 and #24) out of a total sample of 18 residents. Specifically: 1. For Resident #55, #48 and #63 the facility failed to assess their hydration status, draw labs or notify the responsible party before administering intravenous (IV) hydration. 2. For Resident #24 the facility failed to obtain his/her Depakote level as ordered by the Physician.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who has entrusted the facility to manage his/her Personal Needs Account (PNA), the Facility failed to ensure they maintained a system of accounting that assured Resident #1 monthly PNA checks, that were received and processed by the Facility, were then deposited into the correct account, when two of Resident #1 monthly PNA checks were somehow deposited into the Facility's Operations Account, which resulted in Resident #1's account balance to be inaccurate for several months.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 2 Residents (#40 and #370), were free of significant medication errors. Specifically, the facility failed to: 1) implement necessary action when daily administration of Clozapine (an antipsychotic) was ordered by the Physician/NP and was omitted from Resident #40's medication administration for six consecutive days resulting in hospitalization. 2) administer a medication used to treat schizoaffective disorder, resulting in Resident #370 having an increase in symptoms of psychosis and distress.

Inspectors wroteBased on interview, observation and record review, the facility failed to 1. ensure that one Resident (#18) received adequate assistance to prevent an injury, and 2. failed to provide supervision for 1 Resident (#31) out of a total sample of 34 residents. Specifically, on 4/22/23, Resident #18 was transferred out of a bed that was elevated too high and prevented his/her feet to reach the floor. As a result, Resident #18 lost his/her footing and hit his/her left leg on his/her wheelchair and sustained a laceration that required sutures. Specifically, on 4/18/23, supervision was not provided to Resident #31, resulting in Resident #31 entering another resident's room, being screamed at, and falling as he/she exited the room, resulting in an injury and emergency room visit.

Inspectors wroteBased on observation, the facility failed to ensure the building had a home-like environment on 3 of 3 nursing units evidenced by, gouged walls, various stains on the ceilings and walls, broken tiles, rusted toilet paper holders, and rusty detached baseboard covers on 3 of 3 nursing units.

Inspectors wroteBased on record review and interview the facility failed to complete Comprehensive (Annual and Admission) Minimum Data Set (MDS) Assessments in a timely manner for 2 Residents (#59 and #33) and failed to complete a discharge MDS in a timely manner for 1 Resident (#59) out of a total sample of 34 residents.

Inspectors wroteBased on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs.

Inspectors wroteBased on observations, policy review and interviews the facility failed to ensure medication carts were clean, had medications that were stored according to manufacturer's guidelines (refrigerated), and that medications once opened were dated according to manufacturer's guidelines on 3 out of 3 sampled medication carts.

Inspectors wroteBased on observations and interviews, the facility failed to ensure it was administered in a manner that enables it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident.

Inspectors wroteBased on record review and interview the facility failed to ensure they implemented and maintained an effective, comprehensive and data driven Quality Assurance and Performance Improvement (QAPI) program. The facility also failed to make a good faith effort to establish a quality assurance and improvement plan to maintain the quality of life and well-being for residents by failing to offer meaningful, person-centered activities and failing to maintain the building in a homelike manner.

Inspectors wroteBased on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee met quarterly, identified quality deficient areas to develop and implement an appropriate corrective action plans, to ensure satisfactory outcomes. Findings Include: Review of the sign-in sheets for the quarterly QAPI meetings indicated 2 sign-in sheets for the quarterly QAPI meeting held on 1/19/23. The sign-in sheets had signatures of some of the same people but in different ink. One of the sheets indicated the signature of the Medical Director while the other sheet indicated that he attended by phone. Further review failed to indicate a scheduled quarterly QAPI review had taken place. During an interview on 5/03/23, at 3:12 P.M. [...]

Inspectors wroteBased on observation and interviews, the facility failed to implement effective pest control management by not following pest control recommendations as evidenced by mouse activities, droppings on multiple resident rooms, including the kitchen.

Inspectors wroteBased on observation, record review and interview the facility failed to implement the plan of care for 2 Residents (#6, #50) and failed to develop a person-centered care plan with individualized interventions for 2 Residents (#67 and #23) out of a total sample of 34 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to 1.) provide meaningful and person-centered activity programming on one resident care unit out of three resident care units and 2.) failed to provide activities to three Residents (#23, #370, and #67.) out of a total sample of 34 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when 3 out of 3 nurses observed made 7 errors out of 28 opportunities resulting in a medication error rate of 25%. Those errors impacted 4 Residents (#15, #30, #57, and #272) out of 5 residents observed.

Inspectors wroteBased on observation, interview, and test trays, the facility failed to ensure food was served at safe and appetizing temperatures.

Inspectors wroteBased on observations and interview the facility failed to maintain proper sanitation practices related to food storage, food labeling, and food handling.

Inspectors wrote3. For Resident #23 the facility failed to accurately document Resident #23's skin assessment and progress notes related to his/her skin status. Resident #23 was admitted to the facility in February 2023 with diagnoses including sepsis, unsteadiness on feet, asthma, type 2 diabetes mellitus, unspecified dementia, and schizophrenia. Review of the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 2/28/23, indicated Resident #23 had a primary language of Spanish, scored 7 out of 15 on the Brief Interview of Mental Status Exam (BIMS) indicating severe cognitive impairment and required extensive assistance from staff for bed mobility, dressing, hygiene and was dependent on staff for bathing. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain informed consent for the administration a psychotropic medication (Depacote Sprinkles) prior to administration for one Resident (#27) out of a total sample of 34 residents. Resident #27 was admitted in October, 2022 with diagnoses including anxiety and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #27 scored a 99 on the Brief Interview for Mental Status (BIMS), indicating he/she could not participate. The MDS indicated Resident #27 is severely cognitively impaired. Review of the physician orders for Resident #27 indicated the following: - Depakote Sprinkles (a psychotropic medication used to treat seizures and bipolar disorder) Capsule Delayed Release 125 milligrams (mg); give 2 capsule by mouth at bedtime and 1 capsule by mouth two times a day. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to file a grievance for missing personal property for 1 Resident (#21) out of a total of 34 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to report in the required timeframe 1. an injury of unknown source for one Resident (#370) and 2. a resident-to-resident (Resident #67 and Resident #31) verbal altercation resulting in a fall with an injury for one Resident (#31) out of a total sample of 34 residents.

Inspectors wroteBased on record review and interview the facility failed to 1. thoroughly Investigate a bruise of unknown source for one Resident (#370) and 2. failed to investigate a resident-to-resident verbal abuse (Resident #31 and Resident #67) out of a total sample of 34 residents. Review of the facility's policy titled, Abuse Investigation and Reporting, dated March 2017 indicated the following: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall Be Promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 1. [...]

Inspectors wroteBased on record review and interview the facility failed to complete Quarterly Minimum Data Set (MDS) Assessments in a timely manner for 3 Residents (#30, #56, and #9) out of a total sample of 34 residents.

Inspectors wroteBased on record review and interview the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 3 Residents (#50, #22 and #67) out of a total sample of 34 residents.

Inspectors wroteBased on records reviewed, policy review and interview the facility failed to 1. ensure that nursing administered medications that met professional standards of quality for 1 Resident (#22) and 2. failed to ensure professional standards of care for one Resident's (#23) skin, out of 34 sampled Residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide feeding assistance to 1 Resident (#27), resulting in the Resident not eating a meal, out of a total sample of 34 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure care was provided for one Resident (#23), who required extensive assistance. Specifically, Resident #23 was not provided nail care, resulting unclean fingernails out of a total sample of 34 residents.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure quality care was provided to one Resident (#18), out of a total sample of 34 residents. Specifically when on 4/22/23, Resident #18 sustained a laceration to his/her left leg and was transferred to the hospital. Resident #18 returned from the hospital with sutures to his/her left leg and nursing obtained a telehealth visit which resulted in recommendations for antibiotic use and a suture removal date. The facility failed to ensure nursing implemented orders for an antibiotic and a plan for on-going monitoring and assessment of the wound.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure for one Resident (#63) foot care was provided to maintain good foot health, out of a total sample of 34 residents. Specifically, for Resident #63 the facility failed to provide podiatry services for elongated toenails and failed to provide treatment for scaly, dry areas of the foot.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure staff provided appropriate care and services for one Resident (#8) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 34 sampled Residents. Specifically, the facility failed to have and accurate flow rate for feedings and accurate flush settings.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain respiratory equipment according to professional standards of practice for 2 Residents (#22 and #8) out of a total sample of 34 Residents.

Inspectors wroteBased on record review and interview the facility failed to provide care and services consistent with professional standards for one Resident (#22), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working), out of one applicable sampled resident, in a total sample of 34 residents. Specifically, the facility failed to ensure complete and accurate communication with the dialysis facility for the Resident's dialysis appointments.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs on 1 of 3 units.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Nurse #2 was competent and had the required skill set to prepare and administer medications for one Resident (#15), that met professional standards of quality, out of a total sample of 34 Residents. -Nurse #2 crushed medications that should not have been crushed and Nurse #2 did not clean the rubber seal of an insulin pen and she did not prime the insulin pen prior to administering the injection. (removing the air from the needle and the cartridge that may collect during normal use. It is important to prime the pen before each injection so that the injection will work correctly. If a nurse does not prime before each injection, a nurse may give too much or too little insulin, resulting in the incorrect dose being administered.)

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide dental services to one Resident (#34) out of a total sample of 34 residents.

Inspectors wroteBased on record review and interviews the facility failed to implement an effective antibiotic stewardship program for one Resident (#18) out of a total sample of 34 Residents.

Inspectors wroteBased on interview and review of personnel files and training documentation, the facility failed to ensure 2 of 2 certified nurse aides (CNA) and 1 of 1 nurses' were provided with training on dementia management in accordance with State and Federal requirements.