Twin Oaks Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and ensured food and drink were palatable for 3 of 3 residents receiving puree diets. Services. The facility failed to ensure that meals served to residents were palatable on 12/29/25 at 11:00 a.m. when excessively pureed spicy pork chop was served to residents. This failure could place residents at risk of weight loss and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 facility kitchens reviewed for food storage. The facility failed to store food in accordance with professional standards when frozen apple pies were observed stored in a ripped, opened, and undated bag in a freezer in the facility kitchen. The facility failed to store food in accordance with professional standards when pork chops were observed stored in an undated plastic bag in a freezer, and when ham was observed stored in an undated plastic bag in a refrigerator in the facility kitchen. This failure could place residents at risk of food-borne illness and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the residents' status for 2 of 7 residents reviewed for assessments. (Resident #2 and Resident #55)The facility failed to ensure Resident #2's MDS, dated [DATE], was coded for receiving IV medications. The facility failed to ensure Resident #55's MDS, dated [DATE], was coded for the resident having a diabetic foot ulcer. These failures could place residents at risk of not having individual needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals identified with MI, DD, or ID were evaluated for services for 1 of 6 residents (Residents #2) reviewed for PASARR.The facility failed to ensure Resident #2 had a PASARR evaluation after being admitted to the facility on [DATE] with a mental illness diagnoses of bipolar disorder. This failure could place residents at risk of not receiving individualized specialized services to meet their needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (12/29/2025 and 12/30/2025) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 12/29/2025 and 12/30/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were able to remain in the facility and not discharge resident from the facility unless the discharge is necessary for the resident's welfare and the resident's needs cannot be met by the facility. 1 of 3 residents (Resident #1) reviewed for discharge rights. The facility failed to ensure Resident #1's discharged was necessary for his welfare and failed to show the facility could not met his needs. This failure could place residents at risk of unsafe or improper discharge, placing residents at risk of not having appropriate services when discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility did not operate the dish washer at the required temperature for sanitation of dishes. The facility staff was handling the lid of the trash can by the sink after washing their hands. These failures could place residents at risk for food-borne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 1 of 1 smoking area reviewed for smoking. The facility failed to follow their policy on smoking on 9/23/24 when cigarette ashes and multiple cigarette butts were observed in a trash can in smoking area. These failures could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 7 residents (Residents #16, #50 and #53) reviewed for call lights. The facility failed to ensure the emergency call lights in Resident #16, #50, and #53s bathrooms were accessible from the floor on 9/23/2024. These failures could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision with smoking materials to prevent accidents for 2 of 5 residents (Resident #47 and Resident#62) reviewed for accidents and hazards. The facility failed to ensure residents were returning lighters to the staff when returning from smoking. This failure could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observations, interviews, and record review 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 for 4 of 6 residents (Resident #6, #31, #55 and #62) and 4 of 8 staff (CNA A, CNA B, RN M, CNA F) reviewed for infection control. CNA A failed to wear a gown while emptying a foley catheter drainage bag for Resident #6 who was on enhanced barrier precautions on 9/23/2024. CNA B did not sanitize or wash her hands between glove changes and touched clean items with dirty gloves when providing incontinent care to Resident #31 on 9/23/2024. The facility failed to ensure that RN M donned a gown while providing wound care to Resident #55 on 9/24/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 4 of 5 residents (Residents #6, #45, #55, #62) reviewed for immunizations. The facility failed to document education offered for the influenza and pneumococcal vaccination to Residents #6, #45, #55, #62. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.

Inspectors wroteBased on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 4 of 5 residents who were reviewed for immunizations. (Residents #6, #45, #55, #62). The facility failed to document education offered for the covid-19 vaccination to Residents #6, #45, #55, #62. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident # 54) reviewed for resident rights. The facility did not ensure Resident # 54 was spoken to or addressed in a dignified manner. This failure could place residents at risk of decreased feelings of self-worth and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (Resident #5) reviewed for significant medication errors. The facility failed to ensure Resident #5 was free of significant medication errors when a dose of digoxin 125 mcg and metoprolol tartrate 37.5 mg was administered on 09/22/2024. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for, 1 of 6 residents (Resident #324) reviewed for pharmacy services: The facility did not ensure medications were stored properly for Resident #324. Medication was left on bedside table and resident #324 is not care planned to have medication at bedside or self-administer medications. Resident #324 does not have physician orders to have medication at bed side or self-administer. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 3 of 18 residents (Resident #68, #63, #29) reviewed for call lights. The facility failed to ensure Resident #68, #63, and #29's emergency call button in the bathroom had a pull cord from 9/24/2024-9/25/2024. These failures could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to equip corridors with firmly secured handrails for 1 of 4 hallways (hall 400) reviewed for environmental conditions. The facility did not ensure a handrail found on 400 hall was firmly affixed to the wall. This failure could place residents at risk for avoidable accidents and decreased quality of life due to environmental hazards.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program and ensure it was free of pests for 1 of 4 halls (Hall 300) reviewed for pest control. The facility failed to ensure an effective pest control program was in place to keep roaches out of the bathrooms for Resident # 42 and Resident #37. This failure could place residents at risk for injury due to an ineffective pest control program at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 1 of 7 residents reviewed for notification of changes. (Resident #1) Facility failed to ensure the physician was notified when Resident #1 had a change in behavior and complained of pain. An Immediate Jeopardy (IJ) was identified on 01/17/2024 at 4:00 p.m. While the IJ was removed on 01/18/2024 at 8:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction. These failures could place residents at risk for unnecessary pain, delay in treatment, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, for 1 of 7 residents (Resident #1) reviewed for pain management. 1. Facility failed to ensure Resident #1 was adequately assess for pain and administer pain medications as ordered from 12/15/23-12/20/23. 2. Facility failed to ensure the physician was notified when Resident #1 had a change in behavior and complained of pain. 3. Facility failed to ensure the Administrator was notified when Resident #1 had a change in behavior and complained of pain 4. Facility failed to follow their pain management policy by not administering as needed pain medications due to staff not believing pain medication was needed and that Resident #1 needed more facial grimacing. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 of 1 facility self-reported incidents reviewed for reporting to the State Survey Agency. (Incident #471317) The facility failed to report an injury of unknown origin when Resident #1 was found to have a closed displaced oblique fracture of shaft of right humerus. This failure could place the residents at risk for increased risk for abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure the rights of residents to be free from abuse for 3 of 14 residents reviewed for abuse. (Residents #1, #2, and #3) The facility failed to keep Residents #1, #2, and #3 free from verbal abuse by Nurse Aides CNA A, CNA B, and CNA C. The failure could place residents at risk for abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. The noncompliance was identified as PNC. The noncompliance began on 09/05/23 and ended on 09/14/23. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on interview and record review the facility failed to implement policy to ensure the rights of residents to be free from abuse for 3 of 14 residents reviewed for abuse. (Residents #1, #2, and #3) The facility failed to keep Residents #1, #2, and #3 free from verbal abuse by Nurse Aides CNA A, CNA B, and CNA C. The failure could place residents at risk for abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. The noncompliance was identified as PNC. The noncompliance began on 09/05/23 and ended on 09/14/23. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 4 of 12 staff (CNA G, Maintenance Supervisor, Activity Director, and Food Service Supervisor) reviewed for develop and implement abuse policies. The facility failed to ensure the Human Resource (HR) Coordinator implemented the facility's abuse/neglect policy and procedure when she failed to complete an Employee Misconduct Registry (EMR) check for CNA G upon hire and annually for the Maintenance Supervisor, Activity Director, and Food Service Supervisor. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wrote2. Record review of a face sheet dated 07/26/2023 indicated Resident #21 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of stroke, heart disease, and dementia (memory loss). Record review of the Quarterly MDS dated [DATE] indicated Resident #21 was usually understood and usually understands. The MDS in the Recall section indicated Resident #21 was unable to recall, and in the section of orientation of time she was unable to recall the year, month, or the day of the week. Record review of the comprehensive care plan dated 8/30/2020 indicated Resident #21 required the intervention of a fall mat to be free from falls. During an observation on 7/25/2023 at 4:05 p.m., Resident #21's fall mat was up against the wall not on the floor while she was in the bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents environment remained free of accident hazards for 4 of 9 residents (Residents #'s 8, 57, 76, and 180 ) reviewed for accident hazards. The facility failed to ensure the cigarettes and lighters for Resident #'s 57, 76 and 180 were properly secured in the designated locked box behind the nurse's station. The facility failed to complete a smoking assessment for Resident #'s 57 and 180 upon admission. The facility failed to ensure Resident #8 was transferred using a gait belt. These failures could place residents at risk for falls, injuries and decrease quality of life.

Inspectors wroteBased on observation and interview the facility failed to ensure all drugs were only accessible by authorized personnel, labeled and dated correctly for 4 of 4 medication carts (#1 and #2's medication cart and #1 and 2 's nurses' cart) and 1 of 2 medication room refrigerator (Station 1) observed and reviewed for medication storage. 1. The facility failed to ensure medications on #1's medication cart were labeled when opened for Resident #19 and Resident #20. 2. The facility did not ensure #2's medication cart and #1's and #2's nurses' cart were secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for not receiving drugs and biologicals as ordered.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide residents with food and drink that was palatable, attractive, and at a safe and appetizing temperature for two of three residents (Residents #40 and Resident #36) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing taste to Resident #40 and Resident #36, who complained the food did not taste good. This failure could place residents at risk of decreased food intake, weight loss, altered nutritional status, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, 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 for 5 of 7 residents reviewed (Resident #'s 32, 40, 280, 19, and 8) for infection control practices. 1. The facility failed to implement contact isolation for Resident #32 (MRSA) Methicillin-resistant Staphylococcus aureus (a bacteria that causes infections in various parts of the body). 2. The facility failed to implement contact isolation for Resident #40 acquired a urinary tract infection with ESBL (extended spectrum beta-lactamase: enzymes produced by some bacteria making them resistant to some antibiotics). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 1 of 13 rooms (Resident #8's room) and 1 of 1 dining room reviewed for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 10 resident (Resident #40) reviewed for grievances. The facility did not ensure a grievance was completed for Resident #40's complaint of an employee who spilled water on his cellular phone causing the phone to no longer work. This failure could place residents at risk for grievances not being addressed or resolved promptly and a diminished quality of life.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received services to maintain grooming and personal hygiene for 1 of 23 residents (Resident #21) reviewed for ADLs. The facility did not ensure Resident #21's teeth were brushed. This failure could place residents at risk for not receiving services/care and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication room refrigerator reviewed for medication storage (Station 1) and 1 of 3 residents reviewed for missing medication (Resident #42). 1. The facility failed to remove expired medications from station 1 medication room refrigerator. 2. The facility failed to prevent a diversion (missing medication) of Resident #42's Xanax (medication for anxiety {persistent worry or fear}) on 07/25/23. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications.