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Deficiency Records for Twin Oaks Health and Rehabilitation Center
A list of the most recent deficiencies for Twin Oaks Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Twin Oaks Health and Rehabilitation 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-09-24 | 2024-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-09-24 | 2024-10-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-09-24 | 2024-10-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-24 | 2024-10-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-24 | 2024-10-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-09-25 | 2024-09-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-25 | 2024-09-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-09-25 | 2024-09-26 | 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 | 2024-09-25 | 2024-09-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-25 | 2024-09-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-09-25 | 2024-09-26 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-09-25 | 2024-09-26 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-09-25 | 2024-09-26 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2024-09-25 | 2024-09-26 | N |
| Have policies on smoking. | Health | 2024-09-25 | 2024-09-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-09-25 | 2024-09-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-25 | 2024-09-26 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-09-25 | 2024-09-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-18 | 2024-01-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-18 | 2024-01-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-18 | 2024-01-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-29 | 2023-10-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-29 | 2023-09-14 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-14 | 2023-09-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-26 | 2023-08-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-26 | 2023-08-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-26 | 2023-08-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-26 | 2023-08-18 | 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 | 2023-07-26 | 2023-08-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-26 | 2023-08-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-26 | 2023-08-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-26 | 2023-08-18 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-07-26 | 2023-08-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-26 | 2023-08-18 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-15 | 2022-06-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-15 | 2022-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-15 | 2022-06-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-16 | 2022-06-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-09-24 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-14 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-16 | Not Fixed | N |
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