All citations for Twin Oaks Center

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Twin Oaks Center

Last standard health inspection on record

June 18, 2025

Showing 26 to 50 of 82 citations

No harm, with potential for more than minimal harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Widespread (many residents). CMS level F.
Health citation F-0636, Resident Assessment and Care Planning Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 9, 2023).
No harm, with potential for more than minimal harm
Observe each nurse aide's job performance and give regular training.
Widespread (many residents). CMS level F.
Health citation F-0730, Nursing and Physician Services Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 16, 2023).
No harm, with potential for more than minimal harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Widespread (many residents). CMS level F.
Health citation F-0761, Pharmacy Service Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 27, 2023).
No harm, with potential for more than minimal harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Widespread (many residents). CMS level F.
Health citation F-0835, Administration Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (May 9, 2023).
No harm, with potential for more than minimal harm
Have a plan that describes the process for conducting QAPI and QAA activities.
Widespread (many residents). CMS level F.
Health citation F-0865, Administration Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 2, 2023).
No harm, with potential for more than minimal harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Widespread (many residents). CMS level F.
Health citation F-0867, Administration Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 2, 2023).
No harm, with potential for more than minimal harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Widespread (many residents). CMS level F.
Health citation F-0925, Environmental Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (May 15, 2023).
No harm, with potential for more than minimal harm
Install emergency lighting that can last at least 1 1/2 hours.
Widespread (many residents). CMS level F.
Fire safety citation K-0291, Egress Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 9, 2023).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 9, 2023).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Widespread (many residents). CMS level F.
Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 9, 2023).
No harm, with potential for more than minimal harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pattern (more than a few residents). CMS level E.
Health citation F-0761, Pharmacy Service Deficiencies. Inspection of June 18, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2025).
No harm, with potential for more than minimal harm
Ensure services provided by the nursing facility meet professional standards of quality.
Pattern (more than a few residents). CMS level E.
Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of July 11, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (July 11, 2024).
No harm, with potential for more than minimal harm
Install an approved automatic sprinkler system.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0351, Smoke Deficiencies. Inspection of July 11, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (August 5, 2024).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pattern (more than a few residents). CMS level E.
Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 27, 2023).
No harm, with potential for more than minimal harm
Provide activities to meet all resident's needs.
Pattern (more than a few residents). CMS level E.
Health citation F-0679, Quality of Life and Care Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 9, 2023).
No harm, with potential for more than minimal harm
Ensure medication error rates are not 5 percent or greater.
Pattern (more than a few residents). CMS level E.
Health citation F-0759, Pharmacy Service Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 16, 2023).
No harm, with potential for more than minimal harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Pattern (more than a few residents). CMS level E.
Health citation F-0804, Nutrition and Dietary Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 2, 2023).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Pattern (more than a few residents). CMS level E.
Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (May 29, 2023).
No harm, with potential for more than minimal harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Pattern (more than a few residents). CMS level E.
Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of May 3, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (June 9, 2023).
No harm, with potential for more than minimal harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Isolated (one or a few residents). CMS level D.
Health citation F-0550, Resident Rights Deficiencies. Inspection of June 18, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2025).
No harm, with potential for more than minimal harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Isolated (one or a few residents). CMS level D.
Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of June 18, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2025).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Isolated (one or a few residents). CMS level D.
Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of June 18, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2025).
No harm, with potential for more than minimal harm
Ensure services provided by the nursing facility meet professional standards of quality.
Isolated (one or a few residents). CMS level D.
Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of June 18, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2025).
No harm, with potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Isolated (one or a few residents). CMS level D.
Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of June 18, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2025).
No harm, with potential for more than minimal harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Isolated (one or a few residents). CMS level D.
Health citation F-0688, Quality of Life and Care Deficiencies. Inspection of June 18, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (July 24, 2025).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.