Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Oaks Health And Rehab during CMS and state inspections, most recent first.
A facility with 54 residents failed to maintain sanitary dietary standards. Observations revealed uncovered dishware, improperly stored ice machine scoop, undated food containers, and leaking condensation in the freezer. Dietary staff acknowledged the need for proper storage and labeling, as per the facility's guidelines, to prevent food-borne illnesses.
The facility did not implement a system for residents to file grievances anonymously. During a survey, it was found that the grievance form bin in the main lobby was empty, and residents had to request forms from staff. Staff interviews revealed a lack of awareness about the availability of forms in common areas, contrary to the facility's grievance policy, which allowed for anonymous filing.
A resident with a history of CVA, hemiparesis, hemiplegia, and dementia did not have a comprehensive care plan addressing ADL and incontinence care. Despite being dependent on staff for various needs, the care plan lacked specific interventions, leading to an incident of incontinence. Staff confirmed that care plans should include individualized interventions, but this was not reflected in the resident's plan, contrary to facility policy.
A resident with severe cognitive impairment and a history of falls was transported without foot pedals on her wheelchair, leading to her feet dragging on the floor. Despite the facility's policy and care plan requiring foot pedals, staff did not consistently use them, increasing the risk of falls and injury.
A resident with severe cognitive impairment and a history of falls was using a bed cane without a documented safety assessment addressing entrapment risks. The facility did not obtain consent or inform the resident and/or responsible party of the risks and benefits of the bed cane, contrary to its policy requiring assessment of all bed mobility devices.
The facility failed to obtain consent or declinations for the PCV20 vaccine for three residents, despite having a policy to offer pneumococcal vaccinations per CDC guidelines. The residents' records lacked documentation of the vaccine being offered or declined, and the Infection Preventionist confirmed verbal consent for two residents but not for the third. This placed the residents at increased risk for complications related to pneumonia.
The facility did not include the census number in daily posted nurse staffing data, despite having a policy requiring it. Administrative Nurse D attempted different methods to ensure compliance but was unsuccessful. The responsibility was assigned to the night charge nurse, yet the issue persisted.
Sanitary Dietary Standards Not Maintained
Penalty
Summary
The facility, with a census of 54 residents, was found to have failed in maintaining sanitary dietary standards during a survey. Observations in the kitchen revealed several issues: dishware, including plates and open salt/pepper shakers, were stored uncovered and facing upward; the ice machine scoop was placed directly on top of the machine without a sanitary barrier; and opened, undated containers of apple juice were found in the reach-in refrigerator. Additionally, the brewing station had an uncovered metal tin of tea exposed to the air, and the walk-in freezer's air condenser unit was leaking condensation ice onto containers of ice cream. Dietary Staff BB acknowledged that dishware should be stored facing downward and that all food products should be dated and labeled upon opening. The facility's Storage Guidelines policy, revised in November 2017, mandates appropriate storage of food and supplies to ensure quality and safety. These practices were not followed, placing residents at risk of food-borne illnesses and food safety concerns.
Failure to Provide Anonymous Grievance Filing System
Penalty
Summary
The facility failed to implement a system that allowed residents and their representatives to file grievances anonymously. During a walkthrough of the facility, it was observed that the grievance form bin located in the main entry lobby was empty and remained so throughout the survey period. The Resident Council members reported that while a grievance drop-box was available in the main lobby, they had to request forms from the staff, which could then be submitted either to the staff or placed in the box. The council was unaware of any means to obtain the forms without staff assistance. Interviews with facility staff revealed a lack of awareness regarding the availability of grievance forms in common areas. Social Service Staff X stated that forms were kept at nurse stations and the main lobby desk, and residents could request staff assistance to obtain and submit them. However, she was unaware that the main lobby grievance form bin was empty. Similarly, a Certified Medication Aide was uncertain about the availability of forms in common areas, noting that they were kept at nurses' stations. The facility's grievance policy, revised in 2017, indicated that residents should be able to file grievances in writing, verbally, or anonymously, but the facility did not ensure this was possible, placing residents at risk for unresolved grievances.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop comprehensive care plans for a resident, identified as R39, which included necessary interventions for activities of daily living (ADL) and incontinence care. R39's medical history included a cerebrovascular accident (CVA), hemiparesis, hemiplegia, and dementia, with a severely impaired cognition score. The resident was dependent on staff for toileting, transfers, dressing, bathing, personal hygiene, and repositioning, and was at risk for pressure ulcers and had a history of falls. Despite these needs, the care plan lacked specific directions for ADL needs, fall prevention, and incontinence care. Observations and interviews revealed that R39 experienced an incident where she wet the bed, and an incontinence brief was found on the floor, indicating a lack of proper incontinence management. Staff members, including a Certified Medication Aide (CMA) and a Licensed Nurse (LN), confirmed that care plans and Kardex were accessible to all staff, and individualized interventions should be included in the care plans. However, the care plan for R39 did not reflect the necessary individualized and person-centered interventions required for her care. The facility's policy required that a comprehensive care plan be developed within seven days of completing the Minimum Data Set (MDS) and Care Area Assessments (CAAs), with input from the care planning team, the resident, and their family. Despite this policy, the care plan for R39 was not adequately developed to address her specific needs, placing her at risk for impaired care due to uncommunicated care needs.
Failure to Ensure Safe Transport of Resident in Wheelchair
Penalty
Summary
The facility failed to provide a safe environment free from accident hazards for a resident identified as R15. R15 had a medical history including Alzheimer's Disease, hypertension, dysphagia, impulse disorder, and polyneuropathy, and was noted to have severe cognitive impairment. The resident was dependent on staff for mobility and had a history of falls. Despite being at risk for falls, the facility did not ensure the use of foot pedals on R15's wheelchair, which led to her feet dragging on the floor during transport, increasing the risk of falls and injury. Observations and interviews revealed that staff did not consistently use foot pedals when transporting R15, despite the facility's policy and the resident's care plan indicating the need for such safety measures. Staff members acknowledged that residents' feet should not drag during transport, especially for those with cognitive impairments or lower body weakness. The facility's failure to adhere to its falls policy and ensure the use of adaptive equipment like foot pedals contributed to the unsafe environment for R15, placing her at risk for preventable accidents and injuries.
Failure to Document Safety Assessment for Bed Cane Use
Penalty
Summary
The facility failed to ensure that a resident, identified as R25, had a documented safety assessment for the use of side rails, specifically a bed cane, which addressed the risk of entrapment. Additionally, there was no consent obtained for the use of the bed cane, nor were the resident and/or responsible party advised of the risks and/or benefits associated with its use. This deficiency was identified through observations, record reviews, and interviews, revealing that the facility did not follow its own policy regarding the assessment of bed mobility devices, which includes side rails and bed canes. R25, who had severe cognitive impairment due to Alzheimer's disease, was dependent on staff for assistance with various activities of daily living and had a history of falls. Despite these conditions, the facility's records lacked a safety assessment for the bed cane used by R25, and staff interviews indicated a lack of awareness regarding the need for such assessments. The facility's policy required all bed mobility devices to be properly assessed for appropriate indication and safe use, but this was not adhered to in R25's case, placing the resident at risk for uninformed decisions and impaired safety.
Failure to Obtain Consent for PCV20 Vaccination
Penalty
Summary
The facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20) for three residents, placing them at increased risk for complications related to pneumonia. The clinical records of these residents lacked documentation indicating whether the PCV20 was offered or declined, and there was no record of a historical administration of the vaccine. Specifically, Resident 2 had previously received the PCV13 vaccine in 2019, Resident 15 in 2015, and Resident 37 in 2018, with subsequent PPSV23 vaccinations administered in later years. However, there was no documentation of the PCV20 being offered or declined for any of these residents. The facility's policy, last revised in 2017, stated that pneumococcal vaccinations would be offered to all residents per CDC guidelines, with a history of previous vaccinations obtained at the time of admission. Despite this policy, the facility did not offer the PCV20 or obtain informed declinations for the three residents. The facility's Infection Preventionist, responsible for tracking immunizations, confirmed that verbal consent was obtained for Resident 2 and Resident 37, while a message was left for Resident 15's family representative. However, the lack of documented consent or declination for the PCV20 vaccine for these residents constituted a deficiency in the facility's immunization practices.
Failure to Include Census in Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing data included the facility census. The facility had a census of 54 residents, and a sample of 14 residents was included in the review. Upon reviewing daily staffing hour sheets from January 1, 2024, to August 1, 2024, it was found that these sheets lacked the daily facility census number. Administrative Nurse D acknowledged the issue, stating that despite trying different methods to ensure the completion of daily posted nursing hours, the facility had not been successful in including the census number. The responsibility for completing the daily posted staffing hours had been assigned to the night charge nurse. The facility's policy, revised on November 28, 2017, required that the number of licensed and unlicensed nursing personnel providing direct care be posted at the beginning of each shift, including the census number, but this was not adhered to.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lansing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lansing Care And Rehab | 0.8 mi | ★★★★★ | 22 | 0 |
| Medicalodges Leavenworth | 3.6 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Platte City | 8.7 mi | ★★★★★ | 1 | 0 |
| The Healthcare Resort Of Kansas City | 11.1 mi | ★★★★★ | 32 | 0 |
| Providence Place | 11.1 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.