Twin Oaks Nursing Home

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF628Apr 30, 2025

  Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 2 (Resident #3, Resident R1) of 3 (Resident #1, Resident #3, Resident R1) sampled residents reviewed for discharge requirements. Findings: Resident #3 Review of Resident #3's electronic medical record (EMR), in part, revealed he was discharged from the facility on 03/05/2025. Resident R1 Review of Resident R1's EMR, in part, revealed she was discharged from the facility on 01/11/2025. The facility did not present any documented evidence the State's Long-Term Care Ombudsman was notified of Resident #3 or Resident R1's discharge in writing as required.

• No harm, potential for more than minimal, patternF838Apr 30, 2025

  Based on record reviews and interview, the facility failed to ensure its facility-wide assessment addressed the behavioral health needs of its resident population as required . This deficient practice was identified for 3 (Resident #2, Resident #3, Resident #4) of 2 (Resident #2, Resident #3, Resident #4) sampled residents reviewed for behavioral health needs. Findings : Review of the facility's matrix revealed 42 residents were identified as having behavioral health needs Review of the facility's September 2024 facility-wide assessment last revised September 2024 revealed no documented evidence and the facility did not present any documented evidence its facility wide assessment addressed the behavioral health needs of its resident population, staff competencies related to the behavioral… […]

• No harm, potential for more than minimal, patternF677Aug 7, 2024

  Based on observation, interview, and record review, the facility failed to provide nail care for 2 (Resident #28 and Resident #40) of 6 (Resident #24, Resident #28, Resident #40, Resident #47, Resident #61, and Resident #78) sampled residents investigated for activities of daily living (ADLs). Findings: Resident #28 Resident #28 was admitted to the facility on [DATE] with diagnoses of hemiplegia affecting the right side. Review of Resident #28's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/16/2024 revealed she had impairment on one side of her upper and lower extremities. Review of Resident #28's Care Plan revealed Resident #28 required assistance with ADLs with a goal to be kept clean, dry and well-groomed. Observation on 08/06/2024 at 2:20 p.m. […]

• No harm, potential for more than minimal, patternF695Aug 7, 2024

  Based on observations, record reviews, and interviews, the facility failed to develop a plan of care for 1 (Resident #3) of 1 resident (Resident #3) receiving respiratory care by nasal cannula. Findings: Observation on 08/05/2024 at 9:40 a.m. revealed Resident #3 received oxygen at 2 liters per minute (LPM) by nasal cannula. Review of Resident #3's Minimum Data Set (MDS) with an assessment reference date of 04/29/2024 revealed, in part, a brief interview mental status of 13 which indicated cognitively intact. Review of Resident #3's Physician Orders dated August 2024 revealed, in part, no orders for oxygen per nasal cannula. Review of Resident #3's Care Plan revealed, in part, most current target date listed for problems identified was dated 10/01/2024. […]

• No harm, potential for more than minimal, patternF755Aug 7, 2024

  Based on record reviews and interviews, the facility failed to ensure the nursing staff signed a verification of an accurate medication count at the beginning and end of each shift for 2 [Medication Cart (a) and Medication Cart (b)] of 2 [Medication Cart (a) and Medication Cart (b)] Medication Carts (Med Cart) observed and reviewed for accurate dispensation of controlled medications. Findings: Review of the facility's undated Controlled Substances Policy revealed, in part, the nursing staff must count controlled drugs at the end of the shift with the nurse coming on duty and the nurse going off duty. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together. […]