Twin Oaks Rehabilitation and Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF880Oct 26, 2023

  Based on observations, interviews, resident record review, and review of facility policies titled Hand Hygiene, Standard Precautions, and Infection Prevention and Control Program the facility failed to ensure staff provided care to residents, handled soiled linen, lift slings, and mechanical lifts, in a manner to prevent the spread of infection in the facility. On 10/24/2023 during surveyor observations, staff failed to: wash or sanitize hands between residents; dispose of lift slings appropriately after resident use; sanitize the mechanical lift appropriately after resident use. This had the potential to affect Resident Identifier (RI) #81, RI #20, RI #3, and RI #19, four of 28 sampled residents. A facility policy titled Standard Precautions revised 09/2010 documented: . 1. […]

• No harm, potential for more than minimal, isolatedF761Oct 26, 2023

  Based on observation, interviews, and review of a facility policy titled MEDICATION STORAGE IN THE FACILITY, the facility failed to ensure stock Ativan (Lorazepam), a controlled medication, was stored in the medication refrigerator in a secured non-removable container, this was observed on 10/26/2023. This affected one of two medication refrigerators reviewed. Findings include: A facility policy titled MEDICATION STORAGE IN THE FACILITY with a revised date of 08/2014 documented: . CONTROLLED SUBSTANCE STORAGE . Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, . Procedures . C. […]

• No harm, potential for more than minimal, isolatedF755Aug 5, 2021

  Based on interview, review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION and review of facility policies titled, CONTROLLED SUBSTANCE DISPOSAL and MEDICATION DESTRUCTION FOR NON-CONTROLLED MEDICATIONS, the facility failed to ensure the required number of signatures for destruction of controlled and non-controlled medications were present and documented on the destruction forms. This affected two of twelve months reviewed for destruction for the year 2020 and three of six months reviewed for the year 2021. […]