Twin Oaks Health and Rehab

Inspectors wroteThe facility identified a census of 54 residents with one kitchen and three dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to the storage of cookware, dishware, and food. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns. Findings Included: - A walkthrough of the facility's kitchen completed on 08/27/24 at 07:04 AM revealed the following: The dishware storage rack revealed plates, open salt/pepper shakers, and a cake pan stored uncovered and upward. The kitchen's ice machine scoop was stored directly on top of the ice machine without a barrier or sanitary container. The reach-in refrigerator had two opened but undated one-quart box containers of apple juice. [...]

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included: - On 08/27/24 at 07:00 AM a walkthrough of the facility was completed. An inspection of the main entry lobby revealed a grievance box posted to the left side of the lobby. A grievance form bin was next to the grievance box but lacked available grievance forms. The form bin remained empty throughout the survey exit on 08/29/24 at 12:00 PM On 08/28/24 at 01:30 PM, the Resident Council members reported a grievance drop-box was posted in the main lobby. [...]

Inspectors wroteThe facility identified a census of 54. The sample included 14 residents with 14 reviewed for comprehensive care plans. Based on observation, record review, and interview, the facility failed to develop comprehensive care plans that included Resident (R)39's activities of daily living (ADL) and incontinence care. This deficient practice placed the resident at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility reported a census of 54 residents. The sample included 14 residents with four reviewed for accidents. Based on observations, record reviews, and interviews, the facility failed to provide a safe environment free from accident hazards for Residents (R)15. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - The Medical Diagnosis section within R15's Electronic Medical Records (EMR) noted diagnoses of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (high blood pressure), dysphagia (difficulty swallowing), impulse disorder (sudden, forceful, irresistible urges to do something), and polyneuropathy (pain related to damaged neural pathways). [...]

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with four residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R)25 had a documented safety assessment for the use of side rails that addressed entrapment, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the R25 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: [...]

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 2, R15, and R37. This placed the residents at increased risk for complications related to pneumonia.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents. Based on record review and interview, the facility failed to ensure daily posted nurse staffing data included the facility census.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a written notification of transfers with the required information to Resident (R) 3 and R27 or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R3 and R27.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to revise the care plan for Resident (R) 4 to include interventions and treatments for a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) treatment. This deficient practice placed R4 at risk for further avoidable skin damage.

Inspectors wrote- The Diagnoses tab of R3's Electronic Medical Record (EMR) documented diagnoses of hemiplegia and hemiparesis (paralysis and weakness that affects one side of the body), chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), respiratory failure (a serious condition that makes it difficult to breathe on your own). The Annual Minimum Data Set (MDS) dated 05/09/22, documented R3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R3 required extensive assistance to total dependence on staff of two or more for activities of daily living (ADLs). The Quarterly MDS dated 01/12/23 documented R3 had a BIMS score of 15 which indicated intact cognition. R3 required extensive assistance to total dependence on two or more staff for her ADLs. [...]

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with one sampled for dialysis (procedure where impurities or wastes were removed from the blood) review. Based on observations, record review, and interviews, the facility failed to assess Resident (R) 140's arteriovenous (AV) shunt (connection made between and artery and vein for dialysis access) for a thrill (a fine vibration felt which reflects the blood flow by a dialysis resident's shunt) and a bruit (blowing or swishing sound heard which reflects the blood flow with a dialysis resident's shunt) and failed to monitor/assess R140's central dialysis port site to his right upper chest. This deficient practice had the risk for adverse outcomes and physical complications for R140.

Inspectors wroteThe facility identified a census of 47 residents. The facility had one main kitchen and two satellite kitchens. Based on observation, record review and interview, the facility failed to distribute and serve food under sanitary conditions in one satellite kitchen. between the 300 and 400 halls.

Inspectors wroteThe facility identified a census of 47 residents. Based on observations, record reviews, and interviews, the facility failed to perform hand hygiene per standards of practice for infection control and prevention. This deficient practice had the risk to spread illness and infection to all residents and staff.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to adequately provide catheter (a soft hollow tube inserted into the urethra or bladder) care treatment for one resident (R8) sampled. This deficient practice placed R8 at risk for infection at catheter site, urinary tract infection, urinary retention, or possible blockage of the catheter.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents; five residents were sampled for unnecessary medication review. Based on observations, record reviews, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the facility the lack of consistent behavior monitoring for Resident (R) 10 and R30 who received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use.

Inspectors wroteThe facility identified at census of 47 residents. The sample included 12 residents, with five residents sampled for medication review. Based on observation, record review and interview, the facility failed to ensure staff administered Gemtesa (a medication used in treatment for overactive bladder) as ordered by the physician for Resident (R)17. This placed the resident at risk for unnecessary medication administration and unwarranted side effects.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 12 residents; five residents sampled for unnecessary medication review. Based on observations, record reviews, and interviews, the facility failed to provide consistent behavior monitoring for Resident (R) 10 and R30 who received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication and failed to obtain laboratory services as ordered by the physician for R30. This deficient practice had the risk for unwarranted physical complications and unnecessary medication use.