Twin Oaks Health and Rehab

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 24, 2023

  The facility identified a census of 42 residents. The sample included three residents with one resident reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment free from preventable accidents for Resident (R) 1. On 07/12/23 Certified Nurse Aide (CNA) M wheeled R1 into the transportation van to transport R1 to the dialysis (a type of treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to) center. CNA M intentionally did not hook in/secure the front wheels of R1's wheelchair as required to safely secure R1 in the van for transport. CNA N then drove the van 0.2 miles away. When CNA N accelerated the van into the parking lot, R1's wheelchair tipped over. […]

• No harm, potential for more than minimal, widespreadF812Aug 29, 2024

  The facility identified a census of 54 residents with one kitchen and three dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to the storage of cookware, dishware, and food. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns. Findings Included: - A walkthrough of the facility's kitchen completed on 08/27/24 at 07:04 AM revealed the following: The dishware storage rack revealed plates, open salt/pepper shakers, and a cake pan stored uncovered and upward. The kitchen's ice machine scoop was stored directly on top of the ice machine without a barrier or sanitary container. […]

• No harm, potential for more than minimal, patternF585Aug 29, 2024

  The facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included: - On 08/27/24 at 07:00 AM a walkthrough of the facility was completed. An inspection of the main entry lobby revealed a grievance box posted to the left side of the lobby. A grievance form bin was next to the grievance box but lacked available grievance forms. […]

• No harm, potential for more than minimal, patternF812Aug 23, 2021

  The facility identified a census of 47 residents. The facility had one main kitchen and two satellite kitchens. Based on observation, record review and interview, the facility failed to distribute and serve food under sanitary conditions in one satellite kitchen. between the 300 and 400 halls. Findings included: - Observation 08/24/21 at 07:40 AM during breakfast service in the satellite kitchen between 300 and 400 hall Dietary DD served food, then left the service area to grab a cup from a cabinet, returned to service line without performing hand hygiene. […]

• No harm, potential for more than minimal, patternF880Aug 23, 2021

  The facility identified a census of 47 residents. Based on observations, record reviews, and interviews, the facility failed to perform hand hygiene per standards of practice for infection control and prevention. This deficient practice had the risk to spread illness and infection to all residents and staff. Findings included: - On 08/23/21 at 08:18 AM, Certified Medication Aide (CMA) R delivered a covered breakfast plate to Resident (R) 94's room. CMA R did not perform hand hygiene after setting up meal or upon exiting the room. On 08/23/21 at 08:19 AM, CMA R brought a covered glass of milk to R95's in R95's room. CMA R did not perform hand hygiene after delivering the milk and no hand hygiene was observed upon exiting the room. […]