All citations for Twin Oaks Health & Rehabilitation 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 Health & Rehabilitation Center

Last standard health inspection on record

December 31, 2025

Showing 26 to 49 of 49 citations

  1. 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 July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 18, 2023).

  2. No harm, with potential for more than minimal harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 18, 2023).

  3. 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 July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 18, 2023).

  4. 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 July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 18, 2023).

  5. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 18, 2023).

  6. 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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0925, Environmental Deficiencies. Inspection of July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 18, 2023).

  7. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 1, 2023).

  8. No harm, with potential for more than minimal harm

    Ensure each resident receives an accurate assessment.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of December 31, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 5, 2026).

  9. No harm, with potential for more than minimal harm

    PASARR screening for Mental disorders or Intellectual Disabilities

    Isolated (one or a few residents). CMS level D.

    Health citation F-0645, Resident Assessment and Care Planning Deficiencies. Inspection of December 31, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 5, 2026).

  10. No harm, with potential for more than minimal harm

    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0622, Resident Rights Deficiencies. Inspection of April 15, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 4, 2025).

  11. 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 September 25, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (September 26, 2024).

  12. No harm, with potential for more than minimal harm

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of September 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 26, 2024).

  13. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of September 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 26, 2024).

  14. No harm, with potential for more than minimal harm

    Make sure that a working call system is available in each resident's bathroom and bathing area.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0919, Environmental Deficiencies. Inspection of September 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 26, 2024).

  15. No harm, with potential for more than minimal harm

    Put firmly secured handrails on each side of hallways.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0924, Environmental Deficiencies. Inspection of September 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 26, 2024).

  16. 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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0925, Environmental Deficiencies. Inspection of September 25, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (September 26, 2024).

  17. 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 January 18, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 19, 2024).

  18. No harm, with potential for more than minimal harm

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0585, Resident Rights Deficiencies. Inspection of July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 18, 2023).

  19. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 18, 2023).

  20. No harm, with potential for more than minimal harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of July 26, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 18, 2023).

  21. No harm, with potential for minimal harm

    Post nurse staffing information every day.

    Widespread (many residents). CMS level C.

    Health citation F-0732, Nursing and Physician Services Deficiencies. Inspection of December 31, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 5, 2026).

  22. No harm, with potential for minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level C.

    Fire safety citation K-0521, Services Deficiencies. Inspection of December 31, 2025. Found during a standard inspection.

    No follow-up visit needed.

  23. No harm, with potential for minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level C.

    Fire safety citation K-0521, Services Deficiencies. Inspection of September 25, 2024. Found during a standard inspection.

    A waiver was granted.

  24. No harm, with potential for minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level C.

    Fire safety citation K-0521, Services Deficiencies. Inspection of July 26, 2023. Found during a standard inspection.

    A waiver was granted.

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.