Twin Oaks Manor

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #2) of 13 residents reviewed for resident rights. Resident #2 was observed with her catheter bag not in a privacy bag for 3 days exposing her catheter bag to an open hallway and the outside environment. This failure could place residents at risk for feeling uncomfortable and disrespected leading to isolation and deterioration in general health conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions (unless clinically contraindicated) in an effort to discontinue those drugs for 3 (Resident #1, #2, and #7) of 5 residents reviewed for unnecessary medications. Resident #1 was on two psychotropic medications with no attempted gradual dose reductions in the past 12 months. Resident #2 was on one psychotropic medication with no attempted gradual dose reductions in the past 12 months. Resident #7 was on two psychotropic medications with no attempted gradual dose reductions in the past 12 months and one psychotropic medication with one gradual dose reduction completed since admission 5/09/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications. The facility failed to ensure the individual functioning as the Dietary Manger possessed the appropriate certification, training, and qualifications to direct the food and nutrition services department. This failure could place residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure freezer and pantry items were properly stored, labeled, and dated. This failure could place residents at risk of food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 13 residents reviewed for comprehensive care plans. -The facility failed to address the use of a catheter in Resident #1's care plans. This failure could place residents at risk for not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided with such care consistent with professional standards of practice for 1 (Resident #1) of 13 residents reviewed for respiratory care. The facility failed to change the oxygen hydration bottle for Resident #1 for 5 months. This failure could place resident at risk for complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, and serve food in accordance with professional standards for 1 out of 1 kitchen reviewed for food safety. The facility failed to ensure foods were labeled and dated. The facility failed to ensure frozen foods were properly closed. The facility failed to ensure foods and condiments served to residents were not expired. These failures could place residents at risk of food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (the medication room) of 3 medication storage areas reviewed for medication storage. The medication room refrigerator had medications that had been stored out of recommended storage temperatures. The facility's failure could result in a resident receiving a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.

Inspectors wroteBased on interviews and record reviews the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 1 Dietary Manager reviewed for Dietary Manager Certification. The facility failed to ensure the Dietary Manager was certified as a Dietary Manager. This failure could place residents at risk of not having their nutritional needs met and/or a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 1 (CNA B) of 4 staff observed for infection control. -CNA B did not wash her hands while performing incontinent care for Resident #34. This deficient practice placed residents at risk of infections.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. This failure could put place Residents at risk for foodborne illness. Findings Included: Observation of refrigerator one on 3/12/ 24 at 10:58 am revealed 1 container of launchable for staff with no label or date. Observation of refrigerator one on 3/12/24 at 11:08 am revealed 1 tray of individual boxes of vanilla shake milk with no label or date. Observation of refrigerator one on 3/12/24 at 11:08 am revealed 1 bag of parsley with no label or date. Observation of freezer two on 3/12 at 11:15 am revealed 3 packages of ground beef with no date. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for 3 (Resident #8, Resident #16, and Resident #17) and failed to obtain informed consent prior to installation of bedrails for 1 (Resident #31) of 12 residents reviewed for bedrails. 1. Resident #8 had a bedrail on her bed which was placed there on her admission to the facility without prior attempts at appropriate alternatives. 2. Resident #16 had a bedrail on his bed which was placed there on his admission to the facility without prior attempts at appropriate alternatives. 3. Resident #17 had a bedrail on her bed which was placed there on her admission to the facility without prior attempts at appropriate alternatives. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 (Resident #14) of 12 residents reviewed for accuracy of assessment. Resident #14 was coded as having a diagnosis of cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), when he did not, in fact, have cerebral palsy. This failure could lead to residents receiving unnecessary care. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #8 and Resident #14) of 12 residents reviewed for comprehensive person-centered care plans. 1. Resident #8 had a bedrail installed on her bed, but her care plan did not address use of bedrails. 2. Resident #14 was care planned to have supervision during smoking and to have staff keep his cigarettes and lighter, but he was allowed to smoke unsupervised and to have his cigarettes and lighter in his possession. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Resident #14 and Resident #31) of 12 residents reviewed for accidents and hazards. Resident #14 was allowed to keep his lighter and cigarettes in his room and on his person and to smoke unsupervised. Resident #31 was allowed to keep his lighter and cigarettes in his room and he smoked in his room on at least one occasion. These failures could lead to residents being burned or starting a fire in the facility. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days for 1 (Resident #31) of 12 residents reviewed for PRN orders for psychotropic drugs. Resident #31 had an order for a PRN antianxiety medication with a start date of 11/12/23. This failure could place residents at risk of being overmedicated or receiving unnecessary medications. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 Medication Carts (Medication Cart #1 and Medication Cart #2) observed. 4 opened bottles of medications without open dates and 1 expired medication found on A-Hall Medication Cart #1. 5 opened bottles of medications without open dates and 2 expired medications found on B and D Halls Medication Cart #2. The facility's failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain an infection 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 6 of 33 residents observed for sanitation and COVID protocols. The facility did not follow infection control policies related to hand hygiene and source control for COVID- 19 transmission-based precautions for residents that were COVID- 19 positive. This failure could place residents at risk for infections, contamination, physical decline, and mental decline.