Twin Oaks Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Mar 14, 2024

  Based on observation, interview and record review the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. This failure could put place Residents at risk for foodborne illness. Findings Included: Observation of refrigerator one on 3/12/ 24 at 10:58 am revealed 1 container of launchable for staff with no label or date. Observation of refrigerator one on 3/12/24 at 11:08 am revealed 1 tray of individual boxes of vanilla shake milk with no label or date. Observation of refrigerator one on 3/12/24 at 11:08 am revealed 1 bag of parsley with no label or date. […]

• No harm, potential for more than minimal, widespreadF812Nov 10, 2021

  Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 out of 1 facility kitchen; in that: 1) Foods were kept for greater than 6 hours in the refrigerator that read temperatures in the temperature 'danger-zone' of greater than 41 degrees Fahrenheit and less than 135 degrees Fahrenheit. 2) Used mop heads were left under the freezer, the refrigerator and within the refrigerator. 3) Dietary staff (DM, DA A, DA B, and DA C) failed to ensure foods were protected from possible contamination during storage, preparation, and processing. 4) Dry foods and supplies were stored in cardboard boxes that were not elevated off the ground by at least 6 inches. […]

• No harm, potential for more than minimal, patternF550Jun 11, 2026

  Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #2) of 13 residents reviewed for resident rights. Resident #2 was observed with her catheter bag not in a privacy bag for 3 days exposing her catheter bag to an open hallway and the outside environment. This failure could place residents at risk for feeling uncomfortable and disrespected leading to isolation and deterioration in general health conditions. […]

• No harm, potential for more than minimal, patternF605Jun 11, 2026

  Based on observation, interview, and record review the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions (unless clinically contraindicated) in an effort to discontinue those drugs for 3 (Resident #1, #2, and #7) of 5 residents reviewed for unnecessary medications. Resident #1 was on two psychotropic medications with no attempted gradual dose reductions in the past 12 months. Resident #2 was on one psychotropic medication with no attempted gradual dose reductions in the past 12 months. Resident #7 was on two psychotropic medications with no attempted gradual dose reductions in the past 12 months and one psychotropic medication with one gradual dose reduction completed since admission 5/09/2025. […]

• No harm, potential for more than minimal, patternF801Jun 11, 2026

  Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications. The facility failed to ensure the individual functioning as the Dietary Manger possessed the appropriate certification, training, and qualifications to direct the food and nutrition services department. […]