Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Health And Rehabilitation Center during CMS and state inspections, most recent first.
Unpalatable Pureed Pork Chop Served to Residents: The facility failed to ensure pureed meals were palatable for 3 residents on puree diets when a spicy pureed pork chop was served. A dietary staff member added extra spices, including black pepper and a commercial spice blend, and said the puree was too spicy after tasting it. The CDM and ADM also tasted the puree and found it too spicy, and the facility policy stated that texture-modified diet recipes must be followed.
Improper Food Storage in Kitchen: Surveyors observed frozen apple pies in a ripped, opened, and undated bag, along with pork chops and ham stored in undated bags in the kitchen freezer and refrigerator. The CDM and ADM stated that all food should be labeled, dated, and sealed, and the facility policy required open packages to be stored in closed containers or sealed bags and dated when opened.
Inaccurate MDS coding affected two residents. One resident’s MDS did not reflect IV medication administration during the lookback period, even though the TAR showed an IV infusion for wound and skin healing support. Another resident’s MDS did not capture a diabetic foot ulcer or dressing application to the feet, despite the care plan and TAR documenting daily treatment for a diabetic ulcer. The MDS Coordinator acknowledged the coding errors, and the DON and Administrator stated they expected accurate MDS coding.
PASARR screening was not completed for a resident with bipolar disorder after admission. The MDS Coordinator said the diagnosis was not communicated to her and it was missed, and record review showed no PASSR Level II evaluation. The DON and Administrator stated PASSR was the MDS Coordinator’s responsibility and noted communication issues regarding new residents and diagnoses.
Daily nurse staffing information was not posted in a prominent, readily accessible location for residents and visitors. The Staffing Coordinator said she was responsible for the posting but forgot to place it because she was working as a CNA, and the DON and Administrator confirmed the posting was supposed to be displayed daily by the nurses' desk. A placard was later seen behind the nurses' desk, but it did not contain the staffing posting.
A resident with cognitive impairment and behavioral issues was discharged without proper documentation, discharge planning, or notification to the ombudsman. Staff did not follow facility policy, and there was no evidence that the discharge was necessary for the resident's welfare or that the facility could not meet the resident's needs.
The facility did not follow its smoking policy in the designated area, as observed by cigarette ashes and butts in a trash can, with one butt still smoking. Interviews revealed that the maintenance staff responsible for cleaning ashtrays was on vacation, leading to the oversight. The facility's policy requires noncombustible ashtrays with self-closing covers, which were not adequately provided.
The facility's kitchen operations were found deficient due to improper sanitation practices. The dishwasher was operated below the required temperature for sanitization, and staff handled the trash can lid manually after handwashing, compromising hygiene. These issues were observed during a survey, with records indicating a pattern of non-compliance.
The facility failed to ensure that bathroom call lights were accessible for three residents, posing a risk of not being able to notify staff of their needs. Observations revealed that the call lights were wrapped around grab bars, making them inaccessible. The residents involved had varying levels of cognitive impairment and required assistance with toileting. The facility administrator acknowledged the issue and the absence of a call light policy.
Two residents were found with cigarette lighters in violation of the facility's smoking policy, which requires smoking materials to be kept at the nurse's station. One resident, with moderate cognitive impairment, had a history of falling asleep with a lit cigarette, while the other, with no cognitive impairment, insisted on keeping his lighter despite the policy.
A long-term care facility failed to maintain an effective infection prevention and control program, resulting in multiple instances of non-compliance. A CNA did not wear a gown while emptying a foley catheter for a resident on enhanced barrier precautions, and another CNA failed to perform proper hand hygiene during incontinent care. An RN did not don a gown during wound care for a resident with a Stage 4 pressure ulcer, and a CNA allowed a foley catheter drainage bag to touch the ground. These actions could lead to cross-contamination and infection.
The facility failed to document education on influenza and pneumococcal vaccinations for four residents, leading to a deficiency. Despite refusals of vaccines, there was no recorded evidence of education provided or dates of refusal. Interviews confirmed the absence of required documentation, contrary to facility policy.
The facility failed to document COVID-19 vaccination education for several residents, leading to refusals without proper documentation. A resident with cognitive impairment and a history of dementia, another with paraplegia, and others with various medical conditions refused the vaccine without documented education or refusal dates. Interviews revealed a lack of documentation for education on immunization refusals, with the DON acknowledging the risk to residents if not properly educated.
A resident with cognitive impairment and hypertension was mistakenly given another resident's medications, including digoxin and metoprolol, due to a miscommunication between the ADON and a medication aide during administration. The error was identified immediately, and the resident was monitored with no adverse effects reported.
A resident's medication was improperly stored at bedside without physician orders or care planning for self-administration. The resident, with moderately impaired cognition and limited mobility, was unaware of the medication on his nightstand. Facility staff confirmed that medications should be stored in a locked cart, highlighting a lapse in adherence to storage policies.
A facility failed to ensure accessible call systems in bathrooms for three residents, potentially risking their safety. The call lights were either missing pull cords or had cords wrapped, making them unreachable. The residents had cognitive impairments and required varying levels of assistance. The Maintenance Supervisor, responsible for the call lights, was on vacation, and the facility lacked a policy or task list for checking call light strings.
The facility failed to secure a handrail in hall 400, which was found loose and detached from the wall. The DON acknowledged the risk of falls if residents used the handrail for support. The maintenance supervisor, responsible for securing handrails, was on vacation and unavailable. The facility's policy emphasizes the importance of a safe environment, which was compromised by this deficiency.
A resident with depression and anxiety was found on the floor and was yelled at by an LVN, causing her distress. The incident was witnessed by a CNA and the AD, who noted the resident was crying and upset. The facility's policy on resident rights was not upheld, as the resident was not treated with respect and dignity.
The facility failed to maintain an effective pest control program, resulting in roaches in the bathrooms of two residents on Hall 300. Observations showed missing baseboards, allowing pests to enter. The pest control technician noted the facility did not use the pest control log to report issues, and he was unaware of the roach problem until the inspection. Both residents reported seeing roaches, and the facility's pest control policy was not effectively implemented.
Unpalatable Pureed Pork Chop Served to Residents
Penalty
Summary
The facility failed to prepare pureed foods in a palatable manner for 3 of 3 residents receiving puree diets when excessively pureed spicy pork chop was served at lunch. During observation and sample tasting, the surveyor found the pureed pork chops to be spicy, and the dietary staff member who prepared the food stated she had added additional spices, including black pepper and a commercial spice blend. She also stated she tasted the puree and found it to be a little too spicy and said she should have discarded it and prepared more. The CDM stated cooks were responsible for preparing pureed foods and were expected to follow recipes and taste food after seasoning to ensure it was palatable. The CDM later tasted the pork chop puree after being informed of the concern and found it too spicy. The ADM also tasted the puree and found it too spicy, and both the CDM and ADM stated they expected cooks to follow recipes. Record review showed an in-service training attendance roster titled Pureed - Texture/Taste, dated the same day, indicating dietary staff and the CDM attended. The facility policy on texture modified diets stated that recipes must be out and must be followed.
Improper Food Storage in Kitchen
Penalty
Summary
Food was not stored in accordance with professional standards in the facility kitchen when surveyors observed frozen apple pies in a freezer inside a ripped, opened, and undated plastic bag. In the same kitchen observation, pork chops were found in a freezer in an undated plastic bag, and ham was found in a refrigerator in an undated plastic bag. These findings showed that multiple food items were being kept in storage without proper labeling or secure packaging. During interviews, the CDM and facility leadership stated that all food in refrigerators and freezers should be labeled, dated, sealed, and checked by kitchen staff, and that opened, undated, or unlabeled food should be discarded. The CDM said signs were posted to remind staff to check for these issues during daily temperature checks and that she reviewed food in the freezers and refrigerators on Monday and Wednesday. Review of the facility policy titled Food Storage and Supplies stated that open packages of food are to be stored in closed containers or sealed bags and dated when opened.
Inaccurate MDS Coding for IV Medications and Diabetic Foot Ulcer
Penalty
Summary
Ensure each resident receives an accurate assessment. The facility failed to accurately code the MDS for 2 of 7 residents reviewed. Resident #2, a male admitted with diagnoses including congestive heart failure and bipolar disorder, had a quarterly MDS dated 11/24/25 that was not coded for receiving IV medications during the 14-day lookback period. Record review showed he received an IV infusion on 11/18/25 for wound and skin healing support, and he was observed on 12/30/25 sitting in a geri-chair with heel protectors on both feet and a dressing on his right lower extremity. Resident #55, a female admitted with diagnoses including Alzheimer's disease and type 2 diabetes mellitus, had a quarterly MDS dated 12/1/25 that was not coded for a diabetic foot ulcer or for application of dressings to the feet. Record review showed her care plan identified a diabetic foot ulcer related to diabetes, and the TAR documented daily treatments for a diabetic ulcer to the left foot during the lookback period, including cleaning, topical medication, and a dressing. During interview, the MDS Coordinator acknowledged the MDS for Resident #55 was inaccurately coded and stated she had missed coding the IV medications for Resident #2.
PASARR Screening Not Completed for Resident With Bipolar Disorder
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident with a diagnosis of bipolar disorder after admission to the facility. Record review showed the resident was a male admitted with diagnoses including congestive heart failure and bipolar disorder. A quarterly MDS assessment documented a BIMS score of 14, indicating intact cognition, and a prior PASSR Level I screening form had answered “No” to whether there was evidence or an indicator of mental illness. Record review showed there was no PASSR Level II evaluation for the resident. During interview, the MDS Coordinator said she was responsible for PASSR and the resident’s bipolar diagnosis was not communicated to her and “it just got missed.” The DON said the MDS Coordinator was responsible for PASSR, and the Administrator said he expected better communication between staff regarding new residents and diagnoses; he also stated the facility did not have a specific PASSR policy.
Daily nurse staffing posting not displayed
Penalty
Summary
The facility failed to ensure nurse staffing information was posted daily and was readily accessible to residents and visitors with all required information for 2 of 2 days reviewed. During observations on 12/29/2025 at 11:00 a.m. and 12:39 p.m., and again on 12/30/2025 at 9:59 a.m., the daily staff posting was not in or around the front entrance or by the nurse's desk. The report states the facility failed to post the daily staffing information in a prominent place on those dates. During an interview on 12/30/2025, the Staffing Coordinator said she was responsible for putting up the daily staff posting and forgot to post it on 12/29/2025 and 12/30/2025 because she was working on the floor as a nurse aide. She said the posting was used to inform residents, families, and visitors of how many residents and staff were in the facility for the day, and that if it was not put up daily then visitors and families would not have that information. On 12/31/2025, a plastic placard was observed on a wall behind the nurses' desk by the front entrance but it did not contain the staff posting. The DON and Administrator both stated the Staffing Coordinator was responsible for posting it daily, and the Administrator said the facility did not have a policy for the daily staff posting and just followed the regulation.
Failure to Ensure Proper Discharge Procedures and Documentation
Penalty
Summary
The facility failed to ensure that a resident was not discharged without adequate justification and proper documentation. The resident in question had multiple diagnoses, including altered mental status, cognitive disorder, chronic kidney disease, hypertension, lack of coordination, muscle weakness, and hypothyroidism. Despite these conditions, the resident was able to perform activities of daily living independently and was sometimes able to express his needs. The care plan noted verbally aggressive behaviors and interventions such as social services visits and diversional activities, but did not include specific interventions to prevent physical aggression. On the day of the incident, the resident exhibited exit-seeking and aggressive behaviors, including attempting to leave the facility, turning over a table, and trying to throw objects. Staff administered Ativan and monitored the resident, but when behaviors continued, the DON instructed staff to contact the family. A family member, who was also a staff nurse, arrived and found the resident calm. The DON indicated that if the family did not take the resident home, the police would be called. The resident was discharged to the family member's home without a documented discharge plan, and the ombudsman was not notified. The discharge was not documented as necessary for the resident's welfare, nor was there evidence that the facility could not meet the resident's needs. Interviews with facility staff, including the Administrator and compliance nurse, confirmed that facility policy was not followed. There was no documentation from the physician regarding the need for discharge, no interdisciplinary discharge planning, and no assistance provided to the family in locating alternative placement. The facility's own policies require specific documentation and planning for discharges, which were not completed in this case. The ombudsman was not informed, and the discharge summary and medication release documentation were missing.
Failure to Follow Smoking Policy in Designated Area
Penalty
Summary
The facility failed to adhere to its established smoking policy in the designated smoking area. On the specified date, a silver metal trash can was observed in the smoking area, lined with a clear plastic liner containing cigarette ashes. Upon opening the lid, multiple cigarette butts and soda cans were found inside, with one cigarette butt still smoking. This observation indicates a failure to properly dispose of cigarette butts, as per the facility's smoking policy. Interviews conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that the maintenance staff was responsible for cleaning the ashtrays in the smoking areas. However, the maintenance man was on vacation and unavailable, leading to the oversight. The Administrator confirmed that the maintenance supervisor was tasked with checking the smoking area and acknowledged the risk of fire if cigarette butts were disposed of in the trash can. The facility's smoking policy, dated November 1, 2017, mandates the use of ashtrays made of noncombustible materials with a self-closing cover, which were not adequately provided in the smoking area.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, which could potentially place residents at risk for food-borne illnesses. During an observation, it was noted that the kitchen's trash can, located next to the handwashing sink, lacked a foot-operated pedal, leading staff to handle the lid manually after washing their hands. This practice could compromise hand hygiene and food safety. Additionally, the dishwasher was operated at 110 degrees, below the required 120 degrees for proper sanitization, as indicated by the temperature gauge and a metal plate on the dishwasher itself. The record review of the Temperature/Chemical log from September 1 through 24, 2024, showed multiple instances of the dishwasher operating at temperatures between 100-200 degrees, indicating a pattern of non-compliance with the required sanitization temperature. Interviews revealed that the Dietary Aid was aware of the temperature requirement but stated that the hot water had not been turned on by the Dietary Supervisor. The Dietary Supervisor, who was unaware of the issue due to being off sick, mentioned that staff were instructed to use a clean paper towel or towel to open the trash can lid and that frequent in-services were conducted to remind staff about proper dishwasher operation.
Removal Plan
- All kitchen staff have been in-serviced.
- Dietary Aide G has been counseled.
- Dietary Supervisor will check the Temperature/Chemical log.
- Facility will obtain a larger trash can with a foot-operated lid for the kitchen.
Inaccessible Bathroom Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the emergency call lights in the bathrooms of three residents were accessible from the floor, which could prevent residents from notifying staff of their needs. This deficiency was identified during observations and interviews conducted on September 23, 2024. The call lights in the bathrooms of Residents #16, #50, and #53 were found wrapped around the grab bars multiple times, making them inaccessible from the floor. Resident #16, a male with severe cognitive impairment and at risk for falls, required assistance with toileting hygiene and supervision with toilet transfers. Resident #50, a male with moderate cognitive impairment, also required supervision with toileting hygiene and transfers. Resident #53, a female with severe cognitive impairment, required setup assistance for toileting hygiene and transfers. During interviews, Resident #53 mentioned not having had any falls in the bathroom, while Resident #50 acknowledged the presence of the call light but had never needed to use it. The facility administrator admitted that the maintenance man, responsible for ensuring the call lights were long enough and not wrapped around grab bars, was on vacation and unavailable. The administrator acknowledged the risk that residents might not be able to call for help if they were to fall due to the call lights being wrapped around the grab bars. Additionally, the administrator revealed that the facility did not have a call light policy in place.
Inadequate Supervision of Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and management of smoking materials for two residents, leading to potential accident hazards. Resident #47, who has a history of nontraumatic intracerebral hemorrhage and moderate cognitive impairment, was observed with a cigarette lighter on the arm of her wheelchair, despite being informed that smoking materials should be kept at the nurse's station. She had previously fallen asleep with a lit cigarette, indicating a need for supervision while smoking. Resident #62, diagnosed with paraplegia and other significant health issues, was found with a cigarette lighter in his room, contrary to the facility's smoking policy. Although he had no cognitive impairment, he insisted on keeping his smoking materials with him, which violates the policy that requires all smoking materials to be stored at the nurse's station. The facility's administrator acknowledged awareness of these incidents and the existing policy, which prohibits storing ignition sources in residents' rooms.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with established protocols. For Resident #6, who was on enhanced barrier precautions due to an indwelling catheter, CNA A did not wear a gown while emptying the foley catheter drainage bag, despite the requirement to do so during high-contact activities. This oversight was acknowledged by CNA A, who admitted to misunderstanding the necessity of wearing a gown when there was potential contact with the resident's urine. In another instance, CNA B did not perform proper hand hygiene while providing incontinent care to Resident #31, who had a neurogenic bladder and was frequently incontinent. CNA B failed to sanitize or wash her hands between glove changes and touched clean items with dirty gloves. This lapse in protocol was recognized by CNA B, who admitted to not following the correct procedure for hand hygiene, which could lead to cross-contamination and infection. Additionally, RN M did not don a gown while providing wound care to Resident #55, who had a Stage 4 pressure ulcer and was on enhanced barrier precautions. RN M misunderstood the requirement, believing that a gown was only necessary when handling urine. Furthermore, CNA F failed to keep Resident #62's foley catheter drainage bag off the ground, stepping on it twice during wound care assistance. Both CNA F and the Regional Nurse acknowledged the importance of keeping the drainage bag off the floor to prevent infection, yet this protocol was not followed.
Lack of Documentation for Vaccine Education and Refusals
Penalty
Summary
The facility failed to ensure that the medical records of four out of five residents reviewed for immunizations included documentation of education on influenza and pneumococcal vaccinations. This deficiency was identified through interviews and record reviews, which revealed that the residents did not have documented evidence of receiving education about the benefits and potential side effects of these vaccines. The absence of such documentation could lead to residents not being fully informed about their immunization options. Resident #45, a cognitively intact male with a BIMS score of 14, had refused both the influenza and pneumonia vaccines, but there was no documentation of the date of refusal or any educational information provided. Similarly, Resident #55, who had moderate cognitive impairment, also refused both vaccines without any recorded date of refusal or educational documentation. Resident #62, another cognitively intact individual, was not eligible for the flu vaccine and refused the pneumonia vaccine, again with no documentation of education or refusal date. Resident #6, with moderate cognitive impairment, received the flu vaccine but refused the pneumonia vaccine without any documented education or refusal date. Interviews with the Regional Nurse, DON, and Administrator confirmed the lack of documentation and education regarding vaccine refusals. The facility's policy required that a Vaccine Information Statement (VIS) be provided to residents or their representatives, and that documentation of education and refusals be maintained in the clinical record. However, this was not adhered to, as evidenced by the missing documentation in the residents' records.
Failure to Document COVID-19 Vaccination Education
Penalty
Summary
The facility failed to implement its policy to ensure that residents or their responsible parties received education on the benefits, risks, or potential side effects of COVID-19 immunizations. This deficiency was identified for four out of five residents reviewed for immunizations. The facility did not document the education offered to these residents regarding the COVID-19 vaccination, which could place them at risk for contracting a viral disease that could spread through the facility and cause respiratory complications. Resident #45, a cognitively intact male with a history of seizures and hypertension, had a physician's order for the Pfizer COVID vaccine but refused the booster without a documented date of refusal. Resident #55, with moderate cognitive impairment and a history of pressure ulcers and diabetes, did not have an order for the COVID vaccination and refused the vaccine without a documented date of refusal. Resident #62, a cognitively intact male with paraplegia and bipolar disorder, also refused the COVID-19 vaccine without a documented date of refusal. Resident #6, with moderate cognitive impairment and a history of dementia and schizophrenia, had an order for the Pfizer COVID vaccine but refused the booster without a documented date of refusal. Interviews with facility staff revealed that there was no documentation of resident education for immunization refusals. The Regional Nurse stated that nurses were supposed to have residents sign a declination form after being educated if they refused the vaccine, but this was not documented. The Director of Nursing (DON) acknowledged the risk to residents if they were not properly educated and did not receive vaccinations. The Administrator indicated that the DON would be responsible for ensuring that residents were educated on the risks and benefits of immunizations.
Medication Error Due to Miscommunication During Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a dose of digoxin 125 mcg and metoprolol tartrate 37.5 mg was administered to a resident instead of the prescribed medications. The resident, a female with a history of polyneuropathy, essential hypertension, tachycardia, and mild cognitive impairment, was given the wrong medications due to a mix-up during medication administration. The resident's physician was notified, and the resident was monitored for adverse reactions, but no adverse effects were reported. The incident occurred when the Assistant Director of Nursing (ADON) was administering medications and was assisted by a medication aide (MA D). The ADON was taking blood pressures while MA D prepared medications. During this process, the ADON mistakenly administered medications intended for another resident to the resident in question. The error was realized immediately after administration, and the physician was contacted to provide further instructions. The facility's policy on medication administration emphasizes that medications should be poured, administered, and charted by the same licensed person, and the five rights of medication administration should be followed. However, in this case, the policy was not adhered to, leading to the medication error. The administrator acknowledged the error and stated that it would be reviewed during the QA/QI meeting to ensure resident safety.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles for one resident. Specifically, medication was left on the bedside table of a resident who was not care planned to have medication at bedside or to self-administer medications. The resident did not have physician orders to have medication at bedside or to self-administer, and he was observed with medication on his nightstand on multiple occasions. The resident, who had moderately impaired cognition and was bed-confined with limited range of motion, stated he did not self-administer any medications and was unaware of the medication on his nightstand. Interviews with facility staff revealed that medications are not supposed to be stored in residents' rooms and should be kept in a locked medication cart. Staff members acknowledged the risk of leaving medications in residents' rooms, as it could lead to residents taking extra doses or other individuals accessing the medications. The facility's Medication Administration Policy did not address the issue of leaving medications at bedside, and staff were reportedly in-serviced on proper medication storage procedures. Despite these protocols, the incident with the resident's medication being left at bedside occurred, indicating a lapse in adherence to the facility's medication storage policies.
Deficiency in Call System Accessibility
Penalty
Summary
The facility failed to ensure that a working call system was available in the bathrooms and bathing areas for three residents, which could potentially place them at risk of injury, pain, hospitalization, and a diminished quality of life. Specifically, the call lights in the shared bathroom for these residents did not have a pull cord from September 24 to September 25, 2024. Observations revealed that the call light string was wrapped around the call light and would not reach the floor, making it inaccessible for residents to use in case of an emergency. The residents involved had varying degrees of cognitive impairment and required different levels of assistance with toileting. Resident #68 had severe impairment in thinking and was at risk for falls, Resident #63 also had severe cognitive impairment and required assistance with toileting hygiene, and Resident #29 had moderate impairment and was independent with toileting. Interviews with the Regional Nurse and the Administrator indicated that the Maintenance Supervisor was responsible for ensuring the call lights were functional, but he was on vacation at the time of the incident. The facility did not have a policy for call lights, and there was no task list for checking the call light strings, contributing to the oversight.
Unsecured Handrail in Hallway
Penalty
Summary
The facility failed to ensure that the handrails in one of the four hallways reviewed, specifically hall 400, were firmly secured to the wall. During an observation, a handrail was found to be loose and detached from the wall at one end, with the bracket not secured. This was confirmed during an interview with the Director of Nursing (DON), who acknowledged that a loose handrail could lead to falls if residents used it for support. The facility's Administrator also confirmed the issue, noting that the maintenance supervisor, who was responsible for ensuring the handrails were securely attached, was on vacation and unavailable. The facility's policy on resident rights emphasizes the importance of a safe environment, which was compromised by the unsecured handrail.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with respect and dignity, which is a violation of resident rights. The incident involved a female resident with a history of depression, anxiety disorder, and moderately impaired cognition. During an incident, the resident was found on the floor by the Assistant Director (AD), who then called for assistance. When the Licensed Vocational Nurse (LVN) arrived, she began yelling at the resident, questioning why she was on the floor. This interaction was witnessed by the Certified Nursing Assistant (CNA) and the AD, who both noted the resident was crying and upset due to the LVN's behavior. The resident expressed that she was not harmed physically but was upset by the way she was spoken to. The resident's representative mentioned that the resident had previously complained about staff mistreatment, although these complaints were often taken lightly due to the resident's known mood swings and loneliness. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, which was not upheld in this situation.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the bathrooms of two residents on Hall 300. Observations revealed missing baseboards in the bathroom, which allowed pests to enter. The pest control technician, who had been servicing the facility for nine years, noted that the facility did not utilize the pest control log to report issues, and he was not informed of the roach problem until the day of the inspection. The technician confirmed that the absence of baseboards contributed to the pest issue. Resident #42, who has schizoaffective disorder, bipolar disorder, hypothyroidism, and fibromyalgia, and Resident #37, who has COPD, malignant neoplasm of the retroperitoneum, and type 2 diabetes, both reported seeing roaches in their shared bathroom. The facility's pest control policy was not effectively implemented, as evidenced by the incomplete pest control log and the technician's lack of awareness of the roach problem. The facility's administrator acknowledged the risk of infection due to the ineffective pest control program.
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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 Jacksonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Jacksonville | 2.1 mi | ★★★★★ | 1 | 0 |
| Legacy At Jacksonville | 3.1 mi | ★★★★★ | 8 | 0 |
| Bluebonnet Point Wellness | 13.2 mi | ★★★★★ | 8 | 0 |
| Cherokee Trails Nursing Home | 14.2 mi | ★★★★★ | 20 | 0 |
| The Arbors Healthcare And Rehabilitation Center | 15.1 mi | ★★★★★ | 18 | 0 |
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