Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Center during CMS and state inspections, most recent first.
The facility failed to ensure staff received required dementia training and did not implement an effective Infection Prevention and Control Program or Antibiotic Stewardship Program. Administrative leadership was unaware of missing training documentation and did not address clinical concerns in QAPI meetings, while the President of Operations was not informed about the lack of QAPI activities. These failures resulted in deficiencies related to staff competency, infection control, and quality assurance.
The facility's governing body did not provide oversight or accountability for the QAPI and infection control/antibiotic stewardship programs, as evidenced by the absence of documentation, lack of program implementation for several months, and unawareness among leadership regarding program status and responsibilities.
The facility did not maintain a comprehensive, data-driven QAPI program for an extended period following a change in ownership, resulting in the absence of key quality initiatives such as Infection Control and Antibiotic Stewardship. Multiple new staff members were hired without required training, registry checks, or health screenings, and there was no evidence of infection monitoring or reporting to the QAPI committee during this time.
The facility did not ensure its QAPI Committee met as required or addressed quality deficiencies, as the program was not implemented for several months following a change in ownership. During this period, there was also no active Infection Control Program, and essential monitoring and data collection activities were not conducted.
The facility did not implement or maintain an infection prevention and control program, failing to track, monitor, or document infections and outbreaks among residents and staff. Despite multiple antibiotic prescriptions for various infections, there was no evidence of surveillance activities, line listings, or reporting data. The DON, IP, and Administrator were unaware of infection rates or trends, and the Medical Director confirmed the absence of an infection control program.
The facility did not implement or document an Antibiotic Stewardship Program, failing to track, monitor, or review antibiotic use for residents over an extended period. Leadership, including the DON, Infection Preventionist, Administrator, and Medical Director, confirmed the absence of infection surveillance, data collection, and program activities as required by facility policy.
Surveyors found that a medication cart was left unlocked and unattended, allowing unauthorized access to medications. Medications on a cart were not properly labeled or dated when opened, and a medication refrigerator lacked a working thermometer and complete temperature logs, resulting in improper storage conditions for temperature-sensitive drugs. Nursing staff and leadership confirmed these practices did not meet facility policy or manufacturer guidelines.
Staff on one unit failed to provide a dignified dining experience by referring to a resident as a 'feeder' instead of using their name. Both a CNA and a nurse used this term in the dining room, and neither was corrected at the time. Facility policy requires residents to be addressed by name, and leadership confirmed that referring to residents as 'feeders' is not acceptable.
The facility did not timely report two separate incidents involving a resident who suffered a head laceration requiring staples and a right femoral neck fracture requiring surgery. Both events were not reported to the state agency as required by facility policy and regulations, with one incident not reported at all and the other reported ten days late. Interviews with the DON and Administrator confirmed awareness of the incidents and the reporting failures.
A resident with schizophrenia, intellectual disability, and PTSD, who exhibited chronic paranoia and delusions, did not have these behavioral health needs addressed in their care plan. Despite documentation and staff awareness of the resident's specific fears and behaviors, the care plan lacked person-centered interventions as required by facility policy.
Two residents did not receive care in accordance with physician orders: one was administered oxygen without a documented order specifying flow rate or tubing change frequency, and another received enteral feeding with the wrong formula and rate. Nursing staff and leadership confirmed the lack of required orders and failure to follow prescribed instructions.
A resident with peripheral vascular disease and cognitive impairment was observed with a soiled, partially exposed wound dressing on the right ankle that had not been changed for three days, despite physician orders and nursing documentation indicating daily changes. Nursing staff and the DON confirmed that daily dressing changes were expected, but direct observation revealed the deficiency.
A resident with severe cognitive impairment and a contracture in the left hand did not consistently receive a physician-ordered rolled washcloth to the contracted hand every shift. Despite documentation indicating the intervention was completed, multiple observations found the facecloth was not in place, and staff could not provide a documented reason for the omission.
A resident with moderate cognitive impairment and multiple diagnoses experienced significant unmonitored weight loss over several months. Facility staff failed to consistently document weights, perform reweighs, or notify the physician and dietitian as required. Dietary interventions were inconsistently applied, and staff interviews revealed a lack of awareness and follow-up regarding the resident's nutritional status.
Two residents with PTSD and significant trauma histories did not have person-centered care plans addressing their trauma, triggers, or history of suicide attempt. Despite documented histories of abuse, violence, and psychiatric diagnoses, the facility's assessments and care plans failed to identify or address these needs, as confirmed by staff interviews.
A nurse administered medications incorrectly to a resident by giving Lactase tablets after a meal instead of before, and by delivering two sprays of saline nasal solution per nostril instead of the ordered one spray. These actions resulted in a medication error rate of 6.06%, exceeding the regulatory limit of 5%.
A resident with impaired cognition and a history of peripheral vascular disease was repeatedly observed with a soiled, unchanged dressing on an open ankle wound, despite nursing documentation in the MAR indicating daily dressing changes. Nursing staff confirmed the dressing had not been changed as recorded, and the DON could not provide a policy on accurate documentation.
A resident was not offered the Influenza vaccine during influenza season, contrary to facility policy. Record review and staff interviews revealed that vaccination tracking was not being performed, and there was confusion among the DON, Infection Preventionist, and Administrator regarding responsibility for the vaccination program.
A resident was not offered the COVID-19 vaccine upon admission or during their stay, as required by facility policy. Record review confirmed the resident remained unvaccinated, and interviews with the DON, Infection Preventionist, Administrator, and Medical Director revealed a lack of tracking and unclear responsibility for the vaccination program.
A resident with cognitive decline and other health issues was hospitalized due to dehydration, acute kidney injury, and hypernatremia after the facility failed to provide adequate hydration. Despite elevated lab results indicating dehydration, the facility did not initiate a hydration protocol or address the lab values promptly, resulting in a delay in treatment.
A resident with severe cognitive impairment and multiple diagnoses had critically high sodium levels that were not promptly communicated to the physician or NP, resulting in a delay in treatment. The resident was eventually sent to the hospital for hypernatremia, dehydration, and acute kidney injury. The Medical Director noted that immediate notification was expected for such critical lab values.
The facility failed to assess hydration status and obtain consent before administering IV hydration to three residents, and did not conduct a required Depakote level test for another resident. Medical records lacked documentation of hydration assessments and consents, and interviews revealed inconsistencies in the consent process.
Deficient Administrative Oversight in Staff Training, Infection Control, and QAPI
Penalty
Summary
The facility failed to provide appropriate administrative oversight to ensure effective use of resources and to attain the highest practicable well-being of each resident. Specifically, the administration did not ensure that pre-employment health requirements and dementia training were provided to all staff, as evidenced by 3 out of 5 new hire employee records lacking proof of dementia training. Additionally, there was a lack of orientation and education for staff on policies and procedures related to dementia care. The administration also failed to implement and maintain an Infection Prevention and Control Program (IPCP), including the absence of an Antibiotic Stewardship Program for monitoring, tracking, and improving antibiotic use and infection control measures. Interviews revealed that the Administrator was unaware of the missing dementia training documentation and could not provide evidence that clinical concerns, such as infection control and antibiotic stewardship, were discussed in QAPI meetings. The Medical Director confirmed the absence of an Infection Control Program and stated that infection monitoring, data collection, and reporting were not in place. Furthermore, the President of Operations was not informed about the lack of QAPI activities for several months and did not review QAPI minutes to ensure compliance. These failures resulted in deficiencies cited under F837, F880, and F881.
Lack of Governing Body Oversight for QAPI and Infection Control Programs
Penalty
Summary
The facility failed to ensure that its governing body provided oversight and accountability for the maintenance of an effective Quality Assurance and Performance Improvement (QAPI) program and the provision of an infection control/antibiotic stewardship program. Review of facility policy indicated that the Administrator is responsible and accountable to the governing body for QAPI implementation, and that QAPI activities should be a standing agenda item for governing body meetings. However, during the survey, the facility was unable to provide documentation related to infection tracking, reporting data, or antibiotic stewardship, and there was no evidence that QAPI had been initiated for these programs. Interviews revealed that the QAPI program had not been implemented from the time of ownership change in June 2024 until February 2025, with no meeting minutes or projects available for that period. The Administrator was unaware that infection control and antibiotic stewardship programs were not being implemented and had not informed the governing body of the lack of QAPI prior to February. Additionally, the President of Operations/owner was not aware of who the governing body representative was for the facility and was not informed about the absence of QAPI activities during the specified period.
Failure to Implement and Maintain Comprehensive QAPI Program
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, as required. Although a QAPI policy was in place, review of records and staff interviews revealed that the program was not operational from June 2024 until February 2025 following a change in ownership. During this period, there were no QAPI meeting minutes or documented projects, and key quality programs such as Infection Control and Antibiotic Stewardship were not being implemented. The Administrator and Director of Nursing both confirmed that these programs were not in place prior to their recent arrival and that the QAPI program had only recently been re-initiated. Further review of new employee records showed multiple deficiencies in staff onboarding and compliance with regulatory requirements. Several new hires lacked required dementia training, CNA registry checks, preemployment physicals, tuberculin testing, and documentation of COVID vaccination or declination. The Director of Nursing's license was not checked prior to employment. The Medical Director also confirmed the absence of an Infection Control Program and stated that infection monitoring, antibiotic stewardship, and vaccination tracking were not being conducted or reported to the QAPI committee. These findings demonstrate a lack of comprehensive, data-driven quality assurance processes and oversight during the identified period.
Failure to Implement and Maintain QAPI Committee and Infection Control Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) Committee met as required and addressed quality deficiencies through the development and implementation of corrective action plans. According to the facility's own QAPI policy, the committee was supposed to meet monthly and include representatives from key departments to monitor, assess, and improve care and operations. However, the Administrator confirmed that the QAPI program was not implemented from June 2024 until February 2025 following a change in ownership, and no QAPI meeting minutes or projects could be found for that period. Additionally, the Medical Director, who began in April 2025, stated that there was no Infection Control Program in place and that infection monitoring, tracking, and data collection were not occurring as expected. The lack of an active QAPI committee and absence of infection control oversight meant that quality gaps, including those related to infection prevention and antibiotic stewardship, were not being systematically identified or addressed during the specified timeframe.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as required, resulting in the absence of a system for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. Despite having a policy that outlines the responsibilities of the Infection Preventionist (IP) and nursing staff for ongoing surveillance, documentation, and reporting of infections, the facility was unable to provide any documented evidence of infection surveillance activities, line listings, or reporting data for an extended period covering several months. During the survey, the facility could not produce records or documentation related to infection tracking or follow-up activities in response to active antibiotic use, even though electronic records showed multiple antibiotic prescriptions for various infections over several months. Interviews with the DON and IP revealed that they were unaware of infection rates, lacked surveillance data, and did not have information on tracking, trending, or outbreak management. The DON stated reliance on verbal reports from nursing staff and admitted to having no data available, while the IP could not provide evidence of an infection prevention program, including antibiotic stewardship or vaccination tracking. Further, the Administrator acknowledged that the infection control program should be implemented and followed but was not aware of the current infection status in the facility, expecting clinical staff to manage these issues. The Medical Director, who started recently, confirmed the absence of an infection control program and stated that monitoring, tracking, and reporting of infections, as well as antibiotic stewardship and vaccination, were not being conducted as expected. No documentation was available to demonstrate compliance with infection prevention and control requirements.
Failure to Implement Antibiotic Stewardship and Infection Control Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program as required by its own policy and regulatory expectations. Record review showed that there was no documentation of tracking, follow-up, or review with the physician or nurse practitioner after antibiotics were prescribed for three active physician antibiotic orders. Additionally, there was no documented information related to antibiotic use or infection surveillance for a period spanning from August 2024 through June 2025. The facility's policy outlined the need for monitoring antibiotic use, staff education, and tracking of related issues, but these actions were not carried out. Interviews with facility leadership, including the DON, Infection Preventionist, Administrator, and Medical Director, confirmed the absence of an active infection control or antibiotic stewardship program. The DON was unable to provide infection rates or data, relying solely on staff reports. The Infection Preventionist could not produce evidence of any infection prevention activities, including line listings, tracking, or surveillance. The Administrator acknowledged that the program should be in place but was not aware of current infection data, and the Medical Director confirmed the lack of an infection control program, stating that monitoring and tracking were not occurring.
Medication Storage, Labeling, and Temperature Control Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications and biologicals. On one nursing unit, a medication cart was observed left unlocked and unattended, allowing access to medications by unauthorized individuals, including residents who were seen walking past the cart. The nurse responsible for the cart was unaware it was unlocked, and both the nurse and the Director of Nursing confirmed that medication carts are required to be locked at all times when not in use. Additionally, medications on one of the medication carts were not labeled or dated according to manufacturer guidelines. Specifically, a bottle of Artificial Tears Lubricant Eye Drops was found open and undated, and the nurse present could not confirm when it had been opened. The Director of Nursing stated that medications should be dated upon opening and that staff are expected to document this information on the bottle. Further deficiencies were found in the storage of medications requiring refrigeration. The medication refrigerator lacked a functioning thermometer, and temperature logs were incomplete, with only 12 out of 30 days documented for one month. The refrigerator was observed to be too warm, with condensation and melting frost present, and medications inside were wet to the touch. The Assistant Director of Nursing acknowledged the refrigerator was not maintaining proper temperature and that there was no record of how long it had been out of range. The Director of Nursing was unaware of the issue and stated that the affected medications would need to be discarded due to unknown temperature exposure.
Failure to Ensure Dignified Dining Experience Due to Inappropriate Resident Labeling
Penalty
Summary
Facility staff failed to ensure a dignified dining experience for residents on the first floor unit by referring to residents as 'feeders' rather than by their names. Observations included a CNA asking a nurse if a resident was a feeder and the nurse responding affirmatively without correcting the terminology. Additionally, a nurse was heard stating, 'We have a feeder left,' while gesturing to a resident at a table. The facility's policy requires staff to address residents by their names of choice and not by care needs or other labels. Both the Assistant Director of Nursing and the Director of Nursing confirmed during interviews that staff should not refer to residents as feeders.
Failure to Timely Report Serious Resident Injuries to State Agency
Penalty
Summary
The facility failed to report two significant incidents involving a resident to the state agency as required by their own policy and regulatory guidelines. The first incident involved a resident with severe cognitive impairment and dependency on staff for activities of daily living, who experienced a fall resulting in a head laceration that required a staple. The fall was unwitnessed, and the resident was found on the floor by staff. After being transferred to the hospital for evaluation and treatment, the resident returned with a staple in the forehead. Despite the seriousness of the injury, there was no evidence that the incident was reported to the state agency. The second incident involved the same resident, who suffered another unwitnessed fall while in a common area, resulting in a displaced fracture of the right femoral neck that required surgical repair. The resident, who does not ambulate independently and uses a wheelchair, was found on the floor and complained of severe pain in the right knee and lower leg, with visible swelling and deformity. Hospital records confirmed the fracture and subsequent surgery. The facility did not report this incident to the state agency until ten days after the fall, which was not in accordance with the required reporting timelines. Interviews with the Director of Nursing and the Administrator confirmed that both were aware of the incidents and acknowledged that the events should have been reported to the state agency as required. The facility's policy mandates immediate reporting of such incidents, especially those resulting in serious bodily injury, but this protocol was not followed in either case.
Failure to Develop Person-Centered Behavior Care Plan for Resident with Paranoia and Delusions
Penalty
Summary
The facility failed to develop a person-centered behavior care plan for a resident with a history of chronic paranoia and delusions. Despite documented evidence in the hospital discharge records and social work notes indicating the resident's diagnoses of schizophrenia, intellectual disability, and post-traumatic stress disorder, as well as specific behavioral concerns such as paranoia around certain staff and delusional beliefs, the care plan did not address these issues. The resident's behaviors included refusing medication from specific staff and expressing fear and distress related to past experiences, which were not reflected in the individualized care plan. Interviews with facility staff, including the Social Worker and Director of Nurses, confirmed that the resident's chronic paranoia and delusions were not included in the care plan, despite facility policy requiring comprehensive assessment and person-centered planning for residents with impaired cognition or mental illness. The omission was identified during a review of the care plan and supporting documentation, which failed to show any interventions or strategies tailored to the resident's behavioral health needs.
Failure to Follow Physician Orders for Oxygen and Enteral Feeding
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for two residents. For one resident with dementia and COPD, the facility did not have a physician's order specifying the amount of oxygen to be administered via nasal cannula, nor instructions on how often the oxygen tubing should be changed. Observations showed the resident consistently using oxygen at 4 liters with unlabeled and undated tubing, and both the ADON and DON confirmed the absence of a required physician's order and related care plan documentation. For another resident with respiratory failure, gastrostomy, tracheostomy, and quadriplegia, the facility did not implement the physician's order for enteral feeding. The resident was observed receiving a different formula and rate (Jevity 1.2 cal at 58 ml/hr) than what was ordered (Jevity 1.5 cal at 55 ml/hr). Nursing staff were unaware of the discrepancy until it was pointed out, and the DON confirmed that physician's orders should be followed as written.
Failure to Provide Timely Wound Dressing Changes
Penalty
Summary
Surveyors found that the facility failed to provide wound care in accordance with physician orders and professional standards for one resident. The resident, who had diagnoses including peripheral vascular disease, anxiety, and depression, was observed with a soiled dressing on the right ankle that was dated three days prior. The dressing was only partially covering the open wound and had visible yellow/brown drainage. Documentation in the Medication Administration Record indicated that nurses had recorded daily dressing changes as ordered, but direct observation by surveyors contradicted these records. Interviews with nursing staff confirmed that the dressing should have been changed daily according to the physician's orders. The Director of Nursing also stated that her expectation was for nurses to follow the physician's orders for dressing changes. The facility's policy on dressings did not specify adherence to physician orders, and the failure to change the dressing as required resulted in the resident having a soiled and exposed wound for at least three days.
Failure to Provide Ordered Range of Motion Care for Resident with Contracture
Penalty
Summary
The facility failed to consistently implement physician-ordered range of motion (ROM) care for a resident with a contracture in the left hand. The resident, who had severe cognitive impairment and functional limitations in both upper and lower extremities, had a physician's order and care plan directing staff to place a rolled washcloth in the contracted left hand every shift to prevent further deterioration. Despite this, multiple observations over consecutive days showed the resident lying in bed without the required facecloth in the left hand. Interviews with staff, including a CNA and a nurse, confirmed that the facecloth was not in place as ordered, and there was no documented rationale in the medical record for this omission. The Treatment Administration Record (TAR) indicated that the intervention was signed off as completed every shift, despite the facecloth not being present during surveyor observations. The Director of Nursing acknowledged that the facecloth should have been in place per the physician's order and that any deviation should have been documented.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of a resident by not ensuring that significant weight loss was properly assessed and continually monitored. The resident, who had a history of anxiety, depression, and bipolar disorder and demonstrated moderate cognitive impairment, experienced a substantial decrease in weight over several months. Weight records showed a loss of 26.7% from February to May, with missing weight documentation for March and no evidence of reweighs or physician notification regarding the significant weight loss. Dietary notes indicated the resident triggered for weight loss on multiple occasions, but interventions were inconsistently applied, and the resident sometimes declined supplements. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's weight loss. The nurse was unaware of the significant weight loss and did not know if the physician had been notified, while the Registered Dietitian expected nursing staff to identify and report significant changes. The DON confirmed expectations for monthly weights, reweighs, and notifications but was also unaware of the resident's weight loss and the lack of follow-up. The Medication Administration Reports did not indicate that the resident refused supplements, further highlighting gaps in monitoring and documentation.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop trauma-informed, person-centered care plans for two residents with documented histories of post-traumatic stress disorder (PTSD) and significant trauma. For one resident with schizophrenia, intellectual disability, and PTSD, the care plan did not identify or address trauma history, triggers, or interventions to minimize re-traumatization, despite hospital records indicating a history of abuse, family violence, and sexual assault. The Trauma Informed Care Assessment for this resident also failed to document any trauma, and both the Social Worker and Director of Nurses acknowledged that a care plan addressing these issues should have been in place. For another resident with anxiety, depression, bipolar disorder, and PTSD, the care plan did not address the resident's PTSD, history of suicide attempt, or identify triggers that could lead to re-traumatization. Medical records from a previous facility documented a suicide attempt and ongoing psychiatric care, but the Trauma Informed Care Assessment did not reflect this history. Staff interviews confirmed that the care plan should have included interventions for PTSD and suicide risk, but these were not present.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by regulation. During a medication pass observation, one of two nurses made two errors out of 33 opportunities, resulting in a medication error rate of 6.06%. Specifically, a nurse did not follow physician orders for a resident by administering Lactase tablets after the resident had already consumed breakfast, instead of before the meal as ordered. Additionally, the nurse administered two sprays of saline nasal solution in each nostril, rather than the prescribed one spray per nostril. These errors were confirmed through observation, interview, and record review. The nurse acknowledged during an interview that the medications were not administered according to the physician's orders, stating that he should have given the Lactase before the meal and only one spray of saline per nostril. The errors directly impacted one resident who had orders for Lactase for lactose intolerance and saline nasal spray for dryness.
Inaccurate Documentation of Wound Care in Medical Records
Penalty
Summary
Surveyors found that the facility failed to accurately document wound care for one resident with peripheral vascular disease, anxiety, and depression, who had moderately impaired cognition. The resident was observed on multiple occasions with a soiled dressing on the right ankle, dated several days prior, which only partially covered an open wound and showed signs of drainage. Despite this, the Medication Administration Record (MAR) indicated that dressing changes had been documented as completed on three consecutive days. Interviews with nursing staff confirmed that the dressing had not been changed as recorded, and the Director of Nursing acknowledged the expectation for accurate documentation but could not provide a facility policy on the matter. The discrepancy between the observed condition of the dressing and the MAR entries demonstrated a failure to maintain accurate medical records in accordance with professional standards.
Failure to Offer Influenza Vaccine to Resident During Influenza Season
Penalty
Summary
The facility failed to offer the Influenza vaccine to one resident out of a sample of five during the influenza season, as required by facility policy. The policy states that all residents and employees without medical contraindications should be offered the influenza vaccine annually, specifically between October 1st and March 31st. Record review showed that one resident had not been vaccinated for Influenza, and there was no documentation that the vaccine was offered upon admission or during their stay. Interviews revealed a lack of clear responsibility and tracking for the vaccination program. The DON stated she did not track vaccinations and expected the Infection Preventionist to do so, while the Infection Preventionist, new to the facility, was unaware of the vaccination program's status. The Administrator acknowledged the program should be implemented but was not aware of the current vaccination status, and the Medical Director expected vaccination status to be obtained on admission and the vaccine to be offered during influenza season.
Failure to Offer COVID-19 Vaccine to Resident Upon Admission
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to one out of five sampled residents, as required by its own policy and standard infection prevention practices. Record review showed that this resident had not been vaccinated for COVID-19, and there was no documentation that the vaccine had been offered upon admission or during their stay. The facility's policy, revised in January 2023, assigns responsibility to facility leadership and clinical staff to take reasonable measures to protect residents and staff, including offering the COVID-19 vaccine. Interviews revealed a lack of clarity and accountability regarding the vaccination program. The DON stated she does not track vaccinations and expects the Infection Preventionist to do so, while the Infection Preventionist, new to the facility, was unaware of the vaccination program's status. The Administrator acknowledged the program should be implemented but was not aware of the current vaccination status, relying on specialized staff to manage these requirements. The Medical Director, also recently appointed, reported hearing that residents had not been receiving COVID-19 vaccines and expected vaccination status to be obtained on admission and vaccines to be offered if not previously received.
Failure to Maintain Resident Hydration Leads to Hospitalization
Penalty
Summary
The facility failed to maintain the nutrition and hydration status of a resident who required assistance with eating and drinking, leading to hospitalization due to dehydration, acute kidney injury, and hypernatremia. The resident, admitted with conditions including cognitive decline and hypertension, showed a decline in self-feeding ability and required full assistance at meals. Despite recommendations for an occupational therapy evaluation, there was no indication that such an evaluation was conducted. Lab results indicated elevated sodium, chloride, and BUN levels, which were not addressed in a timely manner by the facility staff. The facility's policy on hydration and prevention of dehydration was not followed, as there was no documentation of a hydration protocol being initiated for the resident despite critically high lab values. The nurse practitioner did not address the elevated lab values, and there was a delay in sending the resident to the hospital after receiving notification of critically high sodium levels. The medical director stated that the nurse should have notified the nurse practitioner or physician immediately, considering the delay in treatment a significant issue.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
The facility failed to promptly notify the physician or nurse practitioner of critically high sodium levels for a resident, leading to a delay in treatment. The resident, who had severe cognitive impairment and required assistance with eating and drinking, was admitted with diagnoses including nontraumatic acute subdural hemorrhage, hypertension, peripheral vascular disease, and cognitive decline. Lab results indicated elevated sodium, chloride, and blood urea nitrogen levels, but there was no documentation that the physician or nurse practitioner was informed of these critical values. The lab company confirmed that a nurse was notified of the critically high labs, but the clinical record did not show that the physician or nurse practitioner was informed. Sixteen hours after the facility was initially notified of the elevated labs, the resident was sent to the hospital due to dangerously high sodium levels. The resident was treated in the hospital for hypernatremia, dehydration, and an acute kidney injury. The Medical Director stated that the nurse should have notified the physician or nurse practitioner immediately, considering this a delay in treatment.
Failure to Assess Hydration and Obtain Consent for IV Hydration
Penalty
Summary
The facility failed to meet professional standards of quality care for four residents by not properly assessing hydration status, obtaining necessary consents, and conducting required lab tests. For three residents, the facility administered intravenous (IV) hydration without assessing their hydration status through lab tests or obtaining consent from their health care proxies or guardians. This lack of assessment and communication was evident in the medical records, which did not document any hydration assessments or consent forms prior to the IV administration. In the case of one resident, the facility did not obtain the required Depakote level as ordered by the physician. Despite the physician's and nurse practitioner's notes indicating the need for a Depakote level check on a specific date, the facility failed to arrange for the lab draw. The Director of Nurses acknowledged that the lab draw could have been scheduled even though it was not the facility's regular lab day. Interviews with the Director of Nursing and the Regional Manager of the IV company revealed a discrepancy in the process of obtaining consent for IV hydration. The Director of Nursing stated that consent is always needed from the health care proxy or guardian before proceeding with IV hydration, while the IV technician expected the facility to have obtained consent prior. This inconsistency contributed to the failure to notify and obtain consent from the responsible parties before administering IV hydration.
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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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Nursing homes near Danvers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hunt Nursing & Rehab Center | 0.4 mi | ★★★★★ | 21 | 0 |
| Brentwood Rehabilitation And Healthcare Ctr (the) | 1 mi | ★★★★★ | 6 | 0 |
| Care One At Peabody | 1.8 mi | ★★★★★ | 10 | 0 |
| Hathorne Hill Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 14 | 0 |
| New England Homes For The Deaf, Inc | 2.1 mi | ★★★★★ | 0 | 0 |
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