Inspection Reports for Twin Oaks Convalescent Center
301 S0UTH BAKER STREET, ALMA, GA, 31510
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 6, 2025, found that all previously cited deficiencies from the March 28, 2025, survey were corrected. Prior to that, the facility had deficiencies related to infection control, specifically failure to implement Enhanced Barrier Precautions for a resident with diabetic ulcers, and issues with air conditioning in a resident’s room, which were substantiated in a complaint investigation. Earlier inspections also noted fire safety code violations and multiple care-related deficiencies, including issues with resident dignity, care planning, hygiene, and COVID-19 reporting. Complaint investigations were mostly unsubstantiated or substantiated without deficiencies, except for the March 2025 complaint related to infection control. The facility appears to have addressed recent deficiencies effectively, showing improvement in compliance over the latest inspection cycle.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
73 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 73
Deficiencies: 0
Date: Jun 6, 2025
Visit Reason
A health revisit was conducted to verify correction of deficiencies cited during the March 28, 2025, recertification survey.
Findings
All deficiencies cited as a result of the March 28, 2025, recertification survey were found to be corrected during the revisit.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Twin Oaks Convalescent Center following a survey completed on June 5, 2025.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 13, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Routine
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
A State Licensure survey was conducted at Twin Oaks Convalescent Center from March 25, 2025, through March 28, 2025, to assess compliance with state health regulations.
Findings
The facility failed to implement Enhanced Barrier Precautions (EBPs) for one resident with bilateral diabetic ulcers and weeping lower leg skin tears, placing the resident at risk of increased transmission of infection. Observations and interviews confirmed staff did not wear proper personal protective equipment during wound care.
Deficiencies (1)
Failure to implement Enhanced Barrier Precautions for resident R219 with bilateral diabetic ulcers and weeping lower leg skin tears.
Report Facts
Number of residents sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Observed performing wound care without wearing a gown | |
| Infection Preventionist | Interviewed and stated unawareness of diabetic ulcers requiring Enhanced Barrier Precautions |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 2
Date: Mar 28, 2025
Visit Reason
A standard survey was conducted from March 25, 2025 through March 28, 2025, including investigation of complaint intake number GA00254109, which was substantiated with deficiency.
Complaint Details
Complaint intake number GA00254109 was investigated in conjunction with the standard survey and was substantiated with deficiency.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to implement Enhanced Barrier Precautions for a resident with diabetic ulcers, and failure to ensure an adequate working air conditioner in a resident's room causing discomfort.
Deficiencies (2)
Failure to implement Enhanced Barrier Precautions for one resident with bilateral diabetic ulcers and weeping skin tears.
Failure to ensure one resident's room had an adequate working air conditioner for comfortable temperature.
Report Facts
Census: 72
Room temperature: 80
Room temperature: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | LPN | Mentioned in relation to air conditioner remote control issue in resident R59's room |
| Director of Nursing | DON | Interviewed regarding staff responsibilities for resident comfort |
| Treatment Nurse | TN | Observed performing wound care without proper protective gown |
| Infection Preventionist | IP | Interviewed regarding awareness of resident's diabetic ulcers and need for precautions |
| Maintenance Supervisor | Interviewed about work tickets and training related to air conditioner issues | |
| Maintenance man | Interviewed about air conditioner issues and work tickets | |
| Safety Coordinator | Interviewed and observed regarding air conditioner temperature and remote control issues |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
A State Licensure survey was conducted at Twin Oaks Convalescent Center from March 25, 2025, through March 28, 2025, to assess compliance with state health regulations.
Findings
The facility failed to implement Enhanced Barrier Precautions for one resident with bilateral diabetic ulcers and weeping skin tears, placing the resident at risk of increased infection transmission. Observations and interviews confirmed staff did not wear proper protective equipment during wound care.
Deficiencies (1)
Failure to implement Enhanced Barrier Precautions for resident R219 with bilateral diabetic ulcers and weeping lower leg skin tears.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Observed performing wound care without wearing a gown as required. | |
| Infection Preventionist | Interviewed and stated unawareness that ulcers were diabetic ulcers requiring Enhanced Barrier Precautions. |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 2
Date: Mar 28, 2025
Visit Reason
A standard survey was conducted from March 25, 2025 through March 28, 2025, including investigation of complaint intake number GA00254109, which was substantiated with deficiency.
Complaint Details
Complaint intake number GA00254109 was investigated in conjunction with the standard survey and was substantiated with deficiency.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to implement Enhanced Barrier Precautions for a resident with diabetic ulcers, and failure to ensure an adequate working air conditioner in a resident's room, potentially causing discomfort.
Deficiencies (2)
Failure to implement Enhanced Barrier Precautions for one resident with bilateral diabetic ulcers and weeping skin tears, risking increased transmission of infection.
Failure to ensure one resident's room had an adequate working air conditioner for comfortable temperature, risking resident discomfort.
Report Facts
Facility census: 72
Number of sampled residents for air conditioner deficiency: 22
Room temperature: 80
Room temperature: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff expectations for room temperature comfort |
| Treatment Nurse | Treatment Nurse (TN) | Observed and interviewed regarding failure to wear gown during wound care |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding awareness of diabetic ulcers and need for Enhanced Barrier Precautions |
| Licensed Practical Nurse 3 | Licensed Practical Nurse (LPN) 3 | Interviewed regarding use of remote controls for air conditioner in resident's room |
| Maintenance man | Maintenance man | Interviewed regarding air conditioner issues and work tickets |
| Safety Coordinator | Safety Coordinator | Interviewed regarding air conditioner issues, work tickets, and temperature measurements |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding work tickets and training on remotes for room temperature control |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
A State Licensure survey was conducted at Twin Oaks Convalescent Center from March 25, 2025, through March 28, 2025, to assess compliance with state health regulations.
Findings
The facility failed to implement Enhanced Barrier Precautions (EBPs) for one resident with bilateral diabetic ulcers and weeping lower leg skin tears, placing the resident at risk of increased transmission of infection. Observations and interviews confirmed staff did not wear proper protective gowns during wound care.
Deficiencies (1)
Failure to implement Enhanced Barrier Precautions for resident R219 with bilateral diabetic ulcers and weeping skin tears.
Report Facts
Number of residents sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Observed not wearing gown during wound care for resident R219 | |
| Infection Preventionist | Interviewed regarding awareness of diabetic ulcers on resident R219 |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 2
Date: Mar 28, 2025
Visit Reason
A standard survey was conducted from March 25, 2025 through March 28, 2025, including investigation of complaint intake number GA00254109, which was substantiated with deficiency.
Complaint Details
Complaint intake number GA00254109 was investigated and substantiated with deficiency related to infection control.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to implement Enhanced Barrier Precautions for a resident with diabetic ulcers, and failure to ensure adequate air conditioning in a resident's room causing discomfort.
Deficiencies (2)
Failure to implement Enhanced Barrier Precautions for one resident with bilateral diabetic ulcers and weeping skin tears, increasing risk of infection transmission.
Failure to ensure one resident's room had an adequate working air conditioner for comfortable temperature, causing resident discomfort.
Report Facts
Facility census: 72
Number of sampled residents for air conditioning deficiency: 22
Room temperature: 80
Room temperature: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Observed not wearing gown during wound care for resident R219 | |
| Infection Preventionist | Unaware that ulcers were diabetic ulcers and acknowledged need for Enhanced Barrier Precautions | |
| Licensed Practical Nurse 3 | LPN | Used incorrect remote for air conditioner in resident R59's room |
| Maintenance man | Reported on air conditioning issues and work tickets | |
| Safety Coordinator | Confirmed air conditioner was not working properly and temperature issues | |
| Maintenance Supervisor | Confirmed lack of training on work tickets and remotes for room temperature control | |
| Director of Nursing | Expected staff to check resident comfort regarding room temperature |
Inspection Report
Life Safety
Census: 72
Capacity: 88
Deficiencies: 6
Date: Mar 26, 2025
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to install a breaker lock on the Fire Alarm Control Panel, failure to calibrate or replace fire sprinkler gauges every five years, presence of dust on a sprinkler head, missing escutcheon ring on a sprinkler, use of an extension cord in the lobby, and use of a space heater in a non-allowed area. All issues were confirmed by staff and corrected during the survey.
Deficiencies (6)
Failed to ensure a breaker lock was installed for the Fire Alarm Control Panel (FACP).
Failed to ensure fire sprinkler systems were calibrated or replaced every five years.
Failed to ensure a fire sprinkler head was free from dust.
Failed to ensure an escutcheon ring was installed on the sprinkler in the service room.
Failed to ensure extension cords were not used in the lobby.
Failed to ensure space heaters with thermostatic documentation weren't used in the facility.
Report Facts
Census: 72
Total Capacity: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings and participated in corrective actions during the survey |
Inspection Report
Abbreviated Survey
Census: 70
Deficiencies: 0
Date: Nov 26, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00248405.
Complaint Details
Complaint GA00248405 was unsubstantiated.
Findings
The complaint GA00248405 was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00239325.
Complaint Details
Complaint GA00239325 was substantiated with no regulatory violations cited.
Findings
The complaint GA00239325 was substantiated with no regulatory violations cited.
Inspection Report
Routine
Census: 70
Deficiencies: 14
Date: May 26, 2023
Visit Reason
A Federal Monitoring Comparative survey was conducted at Twin Oaks Convalescent Facility on May 22-25, 2023 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with multiple deficiencies including failure to ensure staff treated residents with dignity during feeding and transfers, inadequate bed accommodations, failure to honor residents' dining preferences, inaccurate assessments of residents' functional limitations, failure to refer residents for required evaluations, incomplete care plan updates, inadequate personal hygiene assistance, failure to prevent contractures, improper use of mechanical lifts, inconsistent respiratory care, lack of behavioral health services, unsecured medication carts, poor food safety and hygiene practices, and failure to ensure hand hygiene during wound care and before meals.
Deficiencies (14)
Staff stood over dependent residents while assisting them to eat and used mechanical lifts in hallways in clear view of others, failing to promote dignity.
Resident's bed did not sufficiently meet accommodation needs causing discomfort.
Facility failed to honor residents' choice to eat dinner in the main dining room.
Inaccurate assessment of functional limitation in range of motion for a resident.
Failure to refer resident for Level II PASARR evaluation for serious mental disorder.
Resident care plan not updated to reflect restorative service recommendations for decreased range of motion and contractures.
Failure to ensure staff shaved residents dependent on staff for personal hygiene.
Failure to provide or follow restorative service recommendations to prevent contractures or decreased range of motion.
Mechanical lift used improperly as a transport device for a resident.
Respiratory care services failed to meet standards; oxygen tubing and water bottle management inconsistent.
Failure to provide behavioral health care and services for resident with depression related to loss of children.
Unattended medication carts left unlocked multiple times, increasing risk of medication errors or diversion.
Poor food safety and hygiene practices including failure to change gloves appropriately, improper storage, and unclean equipment.
Failure to use appropriate hand hygiene between glove changes during wound care and failure to assist residents with hand hygiene before meals.
Report Facts
Deficiencies cited: 13
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | CNA | Named in dignity and feeding assistance deficiency |
| Registered Nurse #2 | RN | Named in mechanical lift use and wound care deficiencies |
| Director of Nursing | DON | Named in multiple findings including mechanical lift use, PASARR referral, behavioral health services |
| Licensed Practical Nurse #1 | LPN | Named in medication cart security deficiency |
| Certified Dietary Manager | CDM | Named in food safety and hygiene deficiencies |
| Occupational Therapy Aide #1 | OTA | Named in restorative services deficiency |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 19, 2023
Visit Reason
A Life Safety Code (LSC) Revisit survey was conducted to verify correction of previously cited LSC deficiencies.
Findings
The survey found that all previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Routine
Census: 69
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
A standard survey was conducted at Twin Oaks Convalescent Center from April 4, 2023 through April 6, 2023 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with the health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B.
Inspection Report
Life Safety
Census: 69
Capacity: 88
Deficiencies: 1
Date: Apr 5, 2023
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to ensure one of seven hazardous rooms was smoke tight, affecting one of three smoke compartments. Specifically, the training room was being used as a storage area and its door was not self-closing, confirmed by staff during the tour.
Deficiencies (1)
Failure to ensure one of seven hazardous rooms was smoke tight; training room door not self-closing.
Report Facts
Census: 69
Certified beds: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings regarding the training room door not being self-closing |
Inspection Report
Deficiencies: 1
Date: Feb 21, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 02/13/2023 and 02/19/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 13, 2023
Visit Reason
The facility was surveyed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 02/06/2023 and 02/12/2023 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 6, 2023
Visit Reason
The report addresses the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 01/30/2023 and 02/05/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 6, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00216727 and GA00218173.
Complaint Details
Complaint GA00216727 was substantiated with no deficiencies cited. Complaint GA00218173 was unsubstantiated with no deficiencies cited.
Findings
Complaint GA00216727 was substantiated with no deficiencies cited, and complaint GA00218173 was unsubstantiated with no deficiencies cited.
Inspection Report
Renewal
Census: 71
Deficiencies: 0
Date: Jul 22, 2021
Visit Reason
A licensure survey was conducted at Twin Oak Convalescent Center from 7/19/2021 through 7/22/2021 to assess compliance with licensure requirements.
Findings
The survey revealed that the facility was in substantial compliance with licensure standards.
Inspection Report
Routine
Census: 71
Deficiencies: 0
Date: Jul 22, 2021
Visit Reason
A standard survey was conducted at Twin Oak Convalescent Center from 7/19/2021 through 7/22/2021 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 69
Capacity: 88
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with LTC 42 CFR § 483.73.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00208137 and #GA00208514.
Complaint Details
Complaints #GA00208137 and #GA00208514 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00208137 and #GA00208514 were unsubstantiated and no regulatory violations were cited.
Inspection Report
Routine
Census: 59
Deficiencies: 0
Date: Aug 12, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on August 11-12, 2020 by Ascellon on behalf of the Georgia Department of Community Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint allegations GA#00201846 and GA#00206669.
Complaint Details
The visit was complaint-related, investigating GA#00201846 and GA#00206669, both substantiated with no deficiencies.
Findings
Both complaint investigations GA#00201846 and GA#00206669 were substantiated with no deficiencies identified.
Inspection Report
Routine
Census: 67
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant CMS and CDC regulations related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 67
Inspection Report
Routine
Census: 71
Deficiencies: 0
Date: Jul 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted at Twin Oaks Convalescent Center on 7/09/2020 through 7/10/2020 to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 8, 2018
Visit Reason
A Revisit Survey was conducted to verify that all deficiencies cited during the standard survey of 9/20/18 were corrected.
Findings
All deficiencies cited as a result of the standard survey conducted on 9/20/18 were found to be corrected during the revisit survey on 11/8/18.
Inspection Report
Life Safety
Census: 84
Capacity: 88
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Emergency Preparedness plan and Life Safety Code requirements during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 5, 2018
Visit Reason
The inspection was conducted as a Complaint Survey on 6/4/18 and 9/5/18 to investigate complaint #GA00188781 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00188781 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 26, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00186834.
Complaint Details
Complaint GA00186834 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 12, 2017
Visit Reason
A follow-up to the Recertification survey of October 26, 2017, was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of December 10, 2017.
Inspection Report
Routine
Census: 85
Deficiencies: 1
Date: Oct 26, 2017
Visit Reason
A standard survey was conducted at Twin Oaks Convalescent Center from October 23, 2017 through October 26, 2017 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to revise/update care plan interventions for one resident (R#49) following a fall, despite the resident requiring extensive assistance and use of a wheelchair. The care plan lacked inclusion of a lap buddy intervention.
Deficiencies (1)
Failure to revise/update care plan interventions for resident R#49 after a fall, specifically omission of lap buddy as an intervention.
Report Facts
Resident census: 85
Sample size: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Registered Nurse | Interviewed regarding failure to add lap buddy intervention to resident R#49's care plan |
Inspection Report
Life Safety
Census: 85
Capacity: 88
Deficiencies: 0
Date: Oct 24, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
Twin Oaks Convalescent Center was found in substantial compliance with the Life Safety Code requirements during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 24, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 21, 2017
Visit Reason
A revisit was conducted on 2/21/17 to the standard survey conducted on 1/5/17 to verify compliance with Federal Regulations for Long Term Care.
Findings
The facility was found to be in compliance with Federal Regulations for Long Term Care, regulations 42 CFR, Part 483, Subpart B effective on 2/19/17 as alleged in their Plan of Correction.
Inspection Report
Routine
Census: 77
Deficiencies: 1
Date: Jan 5, 2017
Visit Reason
The standard QIS survey was conducted from January 3, 2017 to January 5, 2017 to determine compliance with Federal Regulations for Long Term Care.
Findings
The facility failed to ensure a homelike dining environment for thirty-seven residents during two meal services in two dining rooms, as staff left food items and drinks on serving trays instead of placing them on the dining tables in front of residents.
Deficiencies (1)
Failure to provide a safe, clean, comfortable, and homelike environment by not removing food items and drinks from serving trays and placing them on dining tables during meal services.
Report Facts
Residents affected: 37
Census: 77
Residents served in small dining room lunch: 14
Residents assisted feeding small dining room lunch: 12
Residents served in small dining room dinner: 16
Residents assisted feeding small dining room dinner: 12
Residents eating independently large dining room dinner: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and stated unawareness of food items and drinks left on trays during meals | |
| Director of Nursing (DON) | Interviewed and stated unawareness of food items and drinks left on trays during meals | |
| Quality Assurance (QA) Coordinator | Interviewed and confirmed food items and drinks were left on trays during meal service |
Inspection Report
Life Safety
Census: 80
Capacity: 88
Deficiencies: 1
Date: Jan 3, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance at Twin Oaks Convalescent Center.
Findings
The facility was found not in substantial compliance due to failure to provide documentation of inspections, testing, and maintenance of the automatic sprinkler system, specifically the 5-year internal inspection had not been completed.
Deficiencies (1)
Failure to provide records documenting inspections, testing, and maintenance of the automatic sprinkler system, including the 5-year internal inspection.
Report Facts
Certified beds: 88
Census: 80
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