Twin Maples Healthcare, Inc

In the surveyor’s words

From the most serious findings on record at Twin Maples Healthcare, Inc, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 9, 2025

  Based on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 sampled residents (Resident #2), reviewed for falls, the facility failed to transfer the resident per the physician's order, rehabilitation screen, and nurse aide assignment card, which resulted in a fall with multiple fractures. The findings include:Resident #2's diagnoses included Erb's paralysis due to birth injury, hemiplegia affecting the right dominant side and paralytic gait.A review of the Interdisciplinary Therapy Screen conducted by Occupational Therapist (OT) #1 dated 6/23/25 identified Resident #2 was assessed for transfers and was an assist of 2 staff members for Stand, Pivot, Transfer (SPT). […]

• No harm, potential for more than minimal, patternF730May 22, 2025

  Based on review of facility documentation, facility policy and interviews, the facility failed to complete annual nurse aide performance evaluations. The findings include: Interview and review of facility documentation identified the facility employs a total of 25 nurse aides for all three shifts (7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift). Review of the personnel files of NA #1, NA #7, and NA #8 failed to reflect that annual performance evaluations had been completed. Interview with the DNS on 5/21/25 at 12:12 PM identified she has been employed by the facility for 7 years. The DNS indicated she has not completed nurse aide performance evaluations since she has been in the position. […]

• No harm, potential for more than minimal, patternF636Nov 12, 2024

  Based on clinical record reviews, review of facility documentation, facility policies, and interviews for eight (8) of ten (10) sampled residents (Resident #2, #3, #4, #5, #6, #7, #8, and #10) who were reviewed for the completion of a current Minimum Date Set assessment, the facility failed to ensure the assessments were completed within the fourteen (14) day timeframe requirement. The findings include: Resident #2 had a quarterly Minimum Data Set, dated dated dated [DATE] with the status of in process. […]

• No harm, potential for more than minimal, patternF812Jun 22, 2023

  Based on observations during the kitchen tour, review of facility policy and interviews, the facility failed to ensure items were appropriately labeled and dated when opened and failed to discard expired foods prior to the expiration date. The findings include: Observations during a tour of the kitchen on [DATE] at 9:55 AM identified the following: Refrigerator #1 (white) A. Use by date of sour cream was [DATE]. B. Feta shredded cheese lacked both an opened and expiration date. C. American shredded cheese lacking an opened date. D. Mozzarella shredded cheese lacking both an opened and expiration date. E. Parmesan cheese that expired on [DATE]. […]

• No harm, potential for more than minimal, isolatedF585Feb 19, 2026

  Based on clinical record review, facility policy and interviews, for one (1) of three (3) residents (Resident #1) reviewed for grievances, the facility failed to ensure a complaint made by a resident regarding a staff member was referred to the designated grievance official, investigated, and documented with findings and resolution. The findings include:Resident #1's diagnoses included Traumatic Brain Injury (TBI), dementia with behavioral disturbances, conduct disorder, anxiety disorder and psychosis.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), required substantial assistance with bed mobility and was dependent on staff for personal hygiene, toileting and… […]