Twin Oaks Health & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Jan 18, 2024

  Based on interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 1 of 7 residents reviewed for notification of changes. (Resident #1) Facility failed to ensure the physician was notified when Resident #1 had a change in behavior and complained of pain. An Immediate Jeopardy (IJ) was identified on 01/17/2024 at 4:00 p.m. While the IJ was removed on 01/18/2024 at 8:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction. These failures could place residents at risk for unnecessary pain, delay in treatment, and decreased quality of life. […]

• Immediate jeopardy, isolatedF697Jan 18, 2024

  Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, for 1 of 7 residents (Resident #1) reviewed for pain management. 1. Facility failed to ensure Resident #1 was adequately assess for pain and administer pain medications as ordered from 12/15/23-12/20/23. 2. Facility failed to ensure the physician was notified when Resident #1 had a change in behavior and complained of pain. 3. Facility failed to ensure the Administrator was notified when Resident #1 had a change in behavior and complained of pain 4. […]

• No harm, potential for more than minimal, widespreadF812Sep 25, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility did not operate the dish washer at the required temperature for sanitation of dishes. The facility staff was handling the lid of the trash can by the sink after washing their hands. These failures could place residents at risk for food-borne illnesses. Findings included: During an observation in the kitchen on 9/23/2024 at 9:10 AM a trash can next to the kitchen's handwashing sink did not have a foot-operated pedal to open the lid. […]

• No harm, potential for more than minimal, widespreadF926Sep 25, 2024

  Based on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 1 of 1 smoking area reviewed for smoking. The facility failed to follow their policy on smoking on 9/23/24 when cigarette ashes and multiple cigarette butts were observed in a trash can in smoking area. These failures could place residents at risk of injury, burns, and an unsafe smoking environment. Findings include: During an observation on 9/23/24 at 3:36 pm a silver metal trash can was observed in smoking area, it was lined with a clear plastic liner and ashes were observed on the liner. When the lid to trash can was opened, multiple cigarette butts were observed along with soda cans. One cigarette butt was observed still smoking. […]

• No harm, potential for more than minimal, patternF804Dec 31, 2025

  Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and ensured food and drink were palatable for 3 of 3 residents receiving puree diets. Services. The facility failed to ensure that meals served to residents were palatable on 12/29/25 at 11:00 a.m. when excessively pureed spicy pork chop was served to residents. This failure could place residents at risk of weight loss and diminished quality of life.Findings included:During an interview on 12/29/25 at 1:15 p.m., the CDM said cooks were responsible for preparing pureed foods and were expected to follow recipes as provided. The CDM were expected to taste the food after seasoning to ensure it was palatable. […]