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🔎 Twin Oaks Rehabilitation And Nursing Center

Inspection Results


Inspection Overview

Twin Oaks Rehabilitation And Nursing Center has been cited for a total of 92 deficiencies since we began saving each survey.

In California, the average facility has **64.18 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2025-01-29
Correction Date: 2025-02-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2024-10-10
Correction Date: 2024-10-24
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2024-06-20
Correction Date: 2024-06-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2024-06-20
Correction Date: 2024-06-21
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Survey Date: 2024-06-20
Correction Date: 2024-06-21
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-05-07
Correction Date: 2024-05-08
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-05-07
Correction Date: 2024-05-08
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-04-23
Correction Date: 2024-04-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-02-13
Correction Date: 2024-02-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-02-07
Correction Date: 2024-02-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-02-07
Correction Date: 2024-02-29
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2023-12-22
Correction Date: 2024-01-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-12-22
Correction Date: 2024-01-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2023-11-02
Correction Date: 2023-12-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-11-02
Correction Date: 2023-12-28
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-10-10
Correction Date: 2023-10-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2023-05-15
Correction Date: 2023-06-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-03-28
Correction Date: 2023-03-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2023-02-23
Correction Date: 2023-03-23
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide activities to meet all resident's needs.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2022-10-13
Correction Date: 2022-11-17
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2022-07-05
Correction Date: 2022-08-01
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2022-07-05
Correction Date: 2022-08-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-07-05
Correction Date: 2022-08-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2022-05-17
Correction Date: 2022-06-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2022-05-17
Correction Date: 2022-06-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-05-17
Correction Date: 2022-06-22
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2022-03-08
Correction Date: 2022-04-27
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2021-11-30
Correction Date: 2021-12-30
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2021-10-20
Correction Date: 2021-11-18
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-08-23
Correction Date: 2021-09-27
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2021-08-18
Correction Date: 2021-08-31
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-08-18
Correction Date: 2021-08-31
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate foot care.

Survey Date: 2021-06-28
Correction Date: 2021-07-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-06-16
Correction Date: 2021-07-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-06-15
Correction Date: 2021-06-30
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2021-06-09
Correction Date: 2021-06-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-01-14
Correction Date: 2021-01-26
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Survey Date: 2020-12-17
Correction Date: 2020-12-31
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2020-12-17
Correction Date: 2020-12-31
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2020-12-17
Correction Date: 2020-12-31
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely, quality laboratory services/tests to meet the needs of residents.

Survey Date: 2020-10-09
Correction Date: 2020-10-20
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2020-10-05
Correction Date: 2020-10-30
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2020-09-01
Correction Date: 2020-09-24
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to manage his or her financial affairs.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Keep all essential equipment working safely.

Survey Date: 2019-03-21
Correction Date: 2019-04-29
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2018-03-15
Correction Date: 2018-04-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2018-03-15
Correction Date: 2018-04-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-03-15
Correction Date: 2018-04-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Survey Date: 2018-03-15
Correction Date: 2018-04-11
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2018-03-15
Correction Date: 2018-04-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2018-03-15
Correction Date: 2018-04-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2018-03-15
Correction Date: 2018-04-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2018-03-15
Correction Date: 2018-04-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2018-03-15
Correction Date: 2018-04-11
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**