Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Oaks Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, CKD, palliative care needs, and an indwelling Foley catheter had her catheter bag left uncovered and visible from the hallway and even from outside the room on multiple observations. The bag remained exposed while the resident slept, ate, and while other residents and staff were nearby; the ADON, RN, DON, and CNA all stated the bag should be covered for privacy and dignity.
Failure to Complete GDRs for Psychotropic Medications: Three residents receiving psychotropic drugs had no attempted GDRs in the past 12 months, except for one medication for one resident that had a single GDR since admission. One resident with PTSD, depression, and anxiety was receiving quetiapine and trazodone; another resident with major depression and severe cognitive impairment was receiving sertraline; and a third resident with bipolar disorder, anxiety, and depression was receiving paroxetine, bupropion XL, and buspirone. The DON and ADON stated no GDRs had been completed, and the LPH said she was unaware the residents were supposed to have GDRs.
Unqualified Dietary Manager in Food and Nutrition Services: The facility failed to ensure the ADS functioning as the Dietary Manager had the required certification, training, or qualifications to direct dietary services. The ADS stated she was not certified and had only completed limited online DM course work, while staff confirmed she had been in the role for months without completing training. The facility also had no policy identifying qualifications for the Dietary Manager position, and the job duties document did not list required credentials.
Improper Labeling and Dating of Stored Food Items: Surveyors observed multiple freezer and pantry items that were either unlabeled, undated, or both, including meat, bread, pies, vegetables, cereal, and popcorn. The ADS and kitchen staff stated that labeling and dating food was everyone's responsibility, and facility policy required food to be appropriately dated for proper rotation by expiration date.
Missing Care Plan for Foley Catheter: A resident with COPD, CVA, urinary retention, a hx of UTIs, and BPH had an indwelling Foley catheter with orders for monthly changes and catheter care every shift, but the care plan did not address the catheter. The ADON and MDS nurse confirmed the omission, and the DON stated the lack of catheter care planning could affect infection control and care coordination.
A resident with COPD and an order for oxygen at 2L via NC every shift had a hydration bottle on the oxygen concentrator that remained dated and visibly discolored for months. Staff observed the bottle during multiple room checks, and an RN, ADON, and DON all acknowledged that respiratory equipment should be checked and changed routinely, with the facility policy stating humidifier canisters are to be replaced monthly.
Surveyors found that the facility failed to properly label, date, and store food items, with multiple products in the freezer and pantry left open, undated, or expired. Condiments on dining tables were not refrigerated as required and some were past expiration. The Dietary Manager confirmed that these practices could lead to illness. Employee personal food was also stored with facility food, contrary to policy.
The facility did not ensure that medications requiring refrigeration, including insulin pens, were stored within the recommended temperature range. Temperature logs showed repeated instances of the refrigerator reaching 32°F, the freezing point, despite medication labeling indicating they should not be frozen. Staff acknowledged the temperature deviations but could not confirm if the medications had been compromised.
The facility did not ensure that the Dietary Manager maintained current certification, as the certificate had expired and both the Dietary Manager and Administrator were aware of this lapse. There was no facility policy in place regarding the employment of a certified Dietary Manager.
A CNA did not change gloves or perform hand hygiene between removing a soiled brief and applying a clean one for a resident with dementia and incontinence. Despite prior training and facility policy requiring glove changes and handwashing between contaminated and clean care tasks, the CNA proceeded without these steps, as confirmed by interviews with the CNA, ADON, and DON.
Uncovered catheter bag exposed resident to hallway and outside view
Penalty
Summary
The facility failed to treat a resident with respect and dignity and to care for the resident in a manner and environment that promotes quality of life. Resident #2 was an elderly female with chronic kidney disease, palliative care needs, and a wedge compression fracture of the thoracic vertebrae. Her MDS assessment showed a BIMS of 4, indicating severe cognitive impairment, and she was dependent on staff for toileting hygiene and had an indwelling catheter. Her care plan and active orders included a Foley catheter to promote wound healing to a pressure ulcer. During multiple observations, Resident #2’s catheter bag was seen hanging from the bed and exposed to the hallway and outside view without a privacy bag. On one observation, the catheter bag was visible from the window to the sidewalk and street, and the room had no blinds or curtains. On later observations, the catheter bag remained uncovered while the resident slept, ate breakfast, and while other residents and staff were present in the hallway and nearby activity area. An unidentified staff member later placed a privacy bag on the catheter bag during one observation. The ADON, RN D, the DON, and CNA E each stated the catheter bag should be covered for privacy and dignity, and that leaving it uncovered could be a dignity issue.
Failure to Complete Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had gradual dose reductions unless clinically contraindicated. Three of five residents reviewed for unnecessary medications—Resident #1, Resident #2, and Resident #7—were identified as having psychotropic drugs with no attempted gradual dose reductions in the past 12 months, except for one medication for Resident #7 that had one gradual dose reduction completed since admission. The report states this failure could affect residents with excessive sedation, dizziness, blurred vision, weight gain or loss, falls, feelings of isolation, and/or increased depression. Resident #1 was a male admitted originally on 1/01/2025 and readmitted later, with diagnoses including PTSD, depression, and anxiety disorder. His quarterly MDS listed him as severely cognitively impaired, and he was independent with most ADLs. His care plan identified psychotropic medication use and directed staff to monitor for side effects and effectiveness for possible decrease, elimination, or change of psychotropic medication. His active orders included quetiapine 25 mg at bedtime for PTSD and trazodone 100 mg at bedtime for insomnia related to PTSD, and the facility document showed no dose changes since 2/10/25 for quetiapine and 1/01/25 for trazodone. During observation, he was found in bed, did not respond to knocking, and later had loud, mumbled speech that could not be understood. Resident #2 was a female with major depression and severe cognitive impairment, dependent on staff for most ADLs, and on palliative care for failure to thrive. Her active psychotropic order was sertraline 50 mg daily for depression, with the facility document showing the last change on 6/20/2024 and no gradual dose reduction attempted in the past 12 months. Resident #7 was a male with bipolar disorder, anxiety disorder, and depression; his MDS showed intact cognition and partial/moderate supervision with most ADLs. His active orders included paroxetine 40 mg daily, bupropion XL 150 mg daily, and buspirone 15 mg twice daily, with the facility document showing last changes of 5/10/25 for paroxetine and bupropion and 7/09/25 for buspirone. During interview, the DON and ADON stated no GDRs had been completed for Residents #1, #2, and #7, and the LPH stated she was unaware the residents were supposed to have a GDR done and that the residents were stable on their current medications.
Unqualified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietician, because the individual functioning as the Dietary Manager did not possess the required certification, training, or qualifications to direct the department. Record review showed the ADS was hired into the Dietary Manager position on 08/19/25, and a facility receipt dated 4/1/2026 showed payment for her enrollment in an online Dietary Manager training course on 04/10/2026. During interview, the ADS stated she began working in the dietary supervisor role in September 2025, started the online Dietary Manager certification classes in May 2026, was only on the first module, and was not certified as a Dietary Manager. She stated she had completed only some course work in May and had not completed additional work because she felt overwhelmed with her job responsibilities and did not have sufficient time to complete both work duties and the training course. Interviews with facility staff confirmed the ADS was not certified as a Dietary Manager and had been functioning in that role for approximately seven to eight months. The BOM stated the ADS had not completed Dietary Manager training, and the ADM stated the ADS was not certified and that he was responsible for making sure all staff were trained. The ADM also stated the facility did not have a policy identifying qualifications or requirements for the Dietary Manager position. Record review of the facility document titled, Policy and Job Duties Cont., stated the purpose of the supervisor role was to supervise Dietary Services with regularly scheduled consultation from a qualified dietician and that the supervisor was directly responsible to the Administrator, but it did not identify qualifications for the Dietary Supervisor/Dietary Manager position.
Improper Labeling and Dating of Stored Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation. During observation of the freezer, surveyors found multiple items that were not properly labeled or dated, including a bag of breaded meat with no label or date, several bags of white meat and meat that were dated but not labeled, bags of bread that were dated but not labeled, frozen pies in boxes with no label or date, opaque brown bags that were dated but not labeled, frozen breaded vegetables that were dated but not labeled, packages of meat with no label or date, and packages that appeared to be hot dogs or sausages that were dated but not labeled. During observation of the pantry, surveyors found a bag containing what looked like cereal that was dated but not labeled, and two large clear bags containing individual bags of popcorn with no label or date. In interviews, the ADS and kitchen staff stated that it was everyone's responsibility to label and date food and that failure to do so could result in food going bad, residents being served out-of-date food, or residents getting sick. Facility policy stated that all food shall be appropriately dated to ensure proper rotation by expiration dates, and an in-service record stated that labeling and dating items helps ensure food safety compliance and prevents confusion about food type.
Missing Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident that included measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #1 was an [AGE] year-old male admitted and readmitted with diagnoses including COPD, cerebral infarction, urinary retention, history of UTIs, and benign prostatic hyperplasia. His quarterly MDS completed 4/18/26 indicated a BIMS of 99, severe cognitive impairment, independence with most ADLs, and the presence of an indwelling catheter. Active orders included changing a 14FR Foley catheter monthly and PRN and providing catheter care every shift. Record review of the resident’s care plan printed 6/10/26 showed no care plan for catheter use. During observation on 06/09/2026, the resident was sleeping in bed with the catheter bag hanging from the foot of the bed in a privacy bag. The ADON confirmed on 06/11/2026 that the resident had a catheter for several months and did not have a care plan for it, stating that staff unfamiliar with the resident might not know he had a catheter. The MDS nurse also reviewed the chart and stated the catheter was marked on the last MDS but was not addressed in the care plans, saying it was missed. The DON stated that if catheter care was not addressed in the care plan, protocols such as infection control could be violated and staff would not be able to coordinate with the family during a care conference.
Oxygen Hydration Bottle Not Changed for Months
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with COPD, cerebral infarction, atrial fibrillation, and anxiety disorder who was ordered oxygen at 2L per nasal cannula every shift and had a care plan for continuous supplemental oxygen via nasal cannula as ordered. Record review showed the resident was also severely cognitively impaired and listed for oxygen therapy on the quarterly MDS assessment. During observations, the resident was receiving oxygen from an oxygen concentrator with a hydration bottle that was less than one-quarter full, dated 12/30/25, and described as milky and discolored. The same dated hydration bottle was observed again on later observations. An RN stated the bottle should have been checked and changed, and reported that if oxygen equipment was not changed timely and properly, the resident was at risk for mold or bacteria that could result in a respiratory infection. The ADON stated respiratory equipment such as the oxygen hydration bottle should be changed at least monthly, and the DON stated staff should check residents' oxygen each time they were in the room or as needed and that tubing was changed every two weeks. The facility policy stated tubing and humidifier canisters shall be replaced monthly by a charge nurse, except where more frequent replacement is specified.
Deficient Food Storage and Service Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and service practices. During a kitchen tour, several food items in the freezer, such as ice cream, garlic bread, fish sticks, corn dogs, mixed vegetables, pork chops, and corn, were found either open to air, lacking proper closure, or missing labels and dates. In the dry pantry, numerous items including brown sugar, food coloring, gelatin, crackers, drink mixes, coffee, tea, hot sauce, chili powder, soy sauce, gravy mix, and soup were either undated, expired, or not stored according to manufacturer instructions. Additionally, a kitchen employee's personal food was found stored in the refrigerator alongside facility food items. Further observations in the dining area revealed that condiments such as ketchup, mustard, and honey were left on tables for resident use, with some bottles not refrigerated as instructed and others past their expiration dates. The Dietary Manager acknowledged that serving outdated or unrefrigerated foods and condiments could result in residents becoming ill. A review of the facility's food storage policy indicated requirements for proper sealing, dating, and separation of employee personal items, which were not followed as evidenced by the survey findings.
Failure to Maintain Proper Medication Storage Temperatures
Penalty
Summary
The facility failed to ensure that medications were stored in accordance with accepted professional principles in the medication room refrigerator. Review of the refrigerator temperature logs for April 2025 showed multiple instances where the temperature was recorded at 32 degrees Fahrenheit, which is the freezing point of water. Medications stored in the refrigerator at the time of observation included an Ozempic insulin pen labeled 'Do Not Freeze' and two Lantus insulin pens labeled to be stored between 36 to 46 degrees Fahrenheit. Both RN A and the ADON acknowledged that 32 degrees is considered freezing and that freezing could affect the medications, but neither could confirm if the medications had actually frozen. The DON also confirmed that storing medications outside their recommended temperature range could affect their longevity and potency. The facility's policy on medication storage, effective January 2024, requires that medications with specific storage requirements for temperature, light, or humidity must be stored according to those specifications. Despite this policy, the medication room refrigerator was not consistently maintained within the required temperature range for the medications stored inside. There was no documentation or evidence provided that staff took action to address the out-of-range temperatures or to assess the integrity of the affected medications.
Failure to Maintain Certified Dietary Manager
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, specifically by not ensuring that the Dietary Manager maintained current certification. Record review showed that the Dietary Manager's certificate had expired, and during an interview, the Dietary Manager acknowledged awareness of the expired status and indicated plans to register for recertification. The Administrator confirmed prior knowledge of the expired certificate but did not recall specific details about when or with whom the issue was discussed. There was no facility policy regarding the employment of a certified Dietary Manager.
Failure to Follow Hand Hygiene Protocol During Incontinent Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper hand hygiene protocols while assisting with incontinent care for a female resident with dementia, a right hip fracture, macular degeneration, and hallucinations. The resident was severely cognitively impaired, required moderate assistance with activities of daily living, and was frequently incontinent of urine. During the observed care, the CNA washed her hands and donned gloves before starting, but after removing the soiled brief and assisting with positioning the resident, she handled a new brief and completed care without removing her gloves or performing hand hygiene between the contaminated and clean tasks. Interviews with the CNA revealed she did not believe it was necessary to change gloves or wash her hands before applying the new brief, despite having received training on proper hand hygiene. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that facility policy and training require staff to change gloves and perform hand hygiene before moving from a contaminated to a clean task, such as before applying a new brief. Facility policy and the resident's care plan also supported these expectations, but the CNA did not adhere to them during the observed care.
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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 Booker
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capstone Healthcare Of Perryton | 15.8 mi | ★★★★★ | 6 | 0 |
| Beaver County Nursing Home | 24.2 mi | ★★★★★ | 0 | 0 |
| Shattuck Nursing Center | 39.5 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.