CMS Inspection Results for TWIN OAKS CONVALESCENT CENTER

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 05/29/2008 Health Survey for TWIN OAKS CONVALESCENT CENTER

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that follow each resident's written care plan.	Isolated	Actual harm
Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm

 

• 05/29/2008 Fire Safety Survey for TWIN OAKS CONVALESCENT CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Potential for minimal harm

 

• 06/21/2007 Health Survey for TWIN OAKS CONVALESCENT CENTER

Administration
Deficiency	Scope	Level of Harm
Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that staff members wash their hands when needed.	Pattern	Minimal harm or potential for actual harm
Provide bedrooms that don't allow residents to see each other when privacy is needed.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Pattern	Minimal harm or potential for actual harm
Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Widespread	Potential for minimal harm

 

• 06/21/2007 Fire Safety Survey for TWIN OAKS CONVALESCENT CENTER

Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm

 

• 08/10/2006 Health Survey for TWIN OAKS CONVALESCENT CENTER

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that follow each resident's written care plan.	Isolated	Actual harm
Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Widespread	Potential for minimal harm
Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Potential for minimal harm

 

• 08/10/2006 Fire Safety Survey for TWIN OAKS CONVALESCENT CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Potential for minimal harm
Building Contruction
Deficiency	Scope	Level of Harm
a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm