Twin Oaks Center

In the surveyor’s words

From the most serious findings on record at Twin Oaks Center, in the surveyor’s own words.

• Actual harm, patternF760May 3, 2023

  Based on record review and interview, the facility failed to ensure that 2 Residents (#40 and #370), were free of significant medication errors. Specifically, the facility failed to: 1) implement necessary action when daily administration of Clozapine (an antipsychotic) was ordered by the Physician/NP and was omitted from Resident #40's medication administration for six consecutive days resulting in hospitalization . 2) administer a medication used to treat schizoaffective disorder, resulting in Resident #370 having an increase in symptoms of psychosis and distress. Findings include: 1. […]

• Actual harm, isolatedF692Jul 11, 2024

  Based on record review and interview, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#37) out of a total sample of 18 residents. Specifically, the facility failed to provide adequate hydration for a Resident who requires assistance to full dependence for eating and drinking, resulting in a hospitalization due to dehydration, an acute kidney injury, and hypernatremia. Findings include: Review of the facility policy titled Resident Hydration and Prevention of Dehydration, dated 1/22/2015, indicated the following: -This facility will endeavor to provide adequate hydration and to prevent and treat dehydration. […]

• Actual harm, isolatedF773Jul 11, 2024

  Based on record review and interview, the facility failed to promptly notify the physician/ nurse practitioner (NP) of a critically high sodium lab for one Resident (#37), out of a total sample of 18 residents. Findings include: Review of the facility policy titled Resident Hydration and Prevention of Dehydration, dated 1/22/2015, indicated the following: - This facility will endeavor to provide adequate hydration and to prevent and treat dehydration. - Nursing will assess for signs and symptoms of dehydration as needed and notify the provider to determine needs for hydration. - If potential inadequate intake and/or signs and symptoms of dehydration are observed, dehydration protocol will be initiated and documented . Provider will be notify [sic] for further interventions. […]

• Actual harm, isolatedF689May 3, 2023

  Based on interview, observation and record review, the facility failed to 1. ensure that one Resident (#18) received adequate assistance to prevent an injury, and 2. failed to provide supervision for 1 Resident (#31) out of a total sample of 34 residents. Specifically, on 4/22/23, Resident #18 was transferred out of a bed that was elevated too high and prevented his/her feet to reach the floor. As a result, Resident #18 lost his/her footing and hit his/her left leg on his/her wheelchair and sustained a laceration that required sutures. Specifically, on 4/18/23, supervision was not provided to Resident #31, resulting in Resident #31 entering another resident's room, being screamed at, and falling as he/she exited the room, resulting in an injury and emergency room visit. […]

• No harm, potential for more than minimal, widespreadF835Jun 18, 2025

  Based on records reviewed and interviews, the facility failed to ensure it provided appropriate administrative oversight in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to ensure pre-employment health requirements and dementia training was provided to all staff to provide competent, safe, and effective resident care as well as ensuring the governance and leadership members sustain a sufficient Quality Assurance Performance Improvement (QAPI) program during transitions in leadership and staffing. Specifically, the facility administration failed to: 1. […]