TWIN OAKS REHABILITATION AND HEALTHCARE CENTER
For profit - Corporation
131 Beds
BALL HEALTHCARE SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
68/100
#74 of 223 in AL
Photo by Google Street View
Last Inspection: October 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Twin Oaks Rehabilitation and Healthcare Center has a Trust Grade of C+, indicating it is slightly above average but not without its issues. Ranking #74 out of 223 facilities in Alabama places it in the top half, while being #8 of 16 in Mobile County suggests there are only a few better options nearby. Unfortunately, the facility's trend is worsening, with incidents increasing from 1 in 2021 to 2 in 2023. Staffing is a mixed bag; while the turnover rate is a low 37%, indicating stable staff, the facility has below-average RN coverage, being less than 84% of other Alabama facilities, which may impact care quality. Specific incidents have raised concerns, such as a nurse failing to properly clean a blood glucose monitoring device between uses, which poses infection risks, and staff not following hand hygiene protocols or properly storing controlled medications, highlighting lapses in infection control and safety practices.
- Trust Score
- C+
- In Alabama
- #74/223
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near Alabama's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Alabama facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Alabama. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ○ Average
- 6 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
68/100
Top 33%
Review needed
1 → 2 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2021: 1 issues
2023: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Alabama average of 48%
Facility shows strength in fire safety.
The Bad
Staff Turnover: 37%
Near Alabama avg (46%)
Typical for the industry
Chain: BALL HEALTHCARE SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 6 deficiencies on record
1 life-threatening
Oct 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and review of a facility policy titled MEDICATION STORAGE IN THE FACILITY, the facility failed to ensure stock Ativan (Lorazepam), a controlled medication, was stored...
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Based on observation, interviews, and review of a facility policy titled MEDICATION STORAGE IN THE FACILITY, the facility failed to ensure stock Ativan (Lorazepam), a controlled medication, was stored in the medication refrigerator in a secured non-removable container, this was observed on 10/26/2023.
This affected one of two medication refrigerators reviewed.
Findings include:
A facility policy titled MEDICATION STORAGE IN THE FACILITY with a revised date of 08/2014 documented:
. CONTROLLED SUBSTANCE STORAGE .
Policy
Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, .
Procedures .
C. Controlled-substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator.
On 10/26/2023 at 8:30 AM, the medication room on 100 hall was observed with Employee Identifier (EI) #9 Licensed Practical Nurse (LPN). EI #9 removed from the medication refrigerator a plastic storage box with a red lock tag containing two vials of Ativan along with other medications that were not controlled. EI #9 was asked where the ativan was. EI #9 replied, in the plastic box. EI #9 said, there was a secured non-removable box in the refrigerator and it had nothing in it.
On 10/26/2023 at 8:35 AM, EI #2, Director of Nursing (DON), came to the medication room and observed the removal plastic storage box. EI #2 said, the two vials of Ativan was included in the stock medication in the box. EI #2 said, the Ativan should be stored in the non-removable secured box in the refrigerator. EI #2 said, the harm in the Ativan not being secured in the non-removable secured locked box was that, anyone with a key to the medication room and refrigerator could take the medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations, interviews, resident record review, and review of facility policies titled Hand Hygiene, Standard Precautions, and Infection Prevention and Control Program the facility failed t...
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Based on observations, interviews, resident record review, and review of facility policies titled Hand Hygiene, Standard Precautions, and Infection Prevention and Control Program the facility failed to ensure staff provided care to residents, handled soiled linen, lift slings, and mechanical lifts, in a manner to prevent the spread of infection in the facility.
On 10/24/2023 during surveyor observations, staff failed to:
wash or sanitize hands between residents;
dispose of lift slings appropriately after resident use;
sanitize the mechanical lift appropriately after resident use.
This had the potential to affect Resident Identifier (RI) #81, RI #20, RI #3, and RI #19, four of 28 sampled residents.
A facility policy titled Standard Precautions revised 09/2010 documented:
. 1. Hand Hygiene
a. Wash hands after touching . contaminated items .
5. Resident-Care Equipment .
a. Handle used resident-care equipment soiled with blood, body fluid, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments.
b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed .
A facility policy titled Hand Hygiene dated 05/2020 revealed:
. PURPOSE: To provide guidelines to employees for proper and appropriate hand hygiene techniques that will aide in the prevention of the transmission of infections.
Hand hygiene should be performed using Alcohol Based Hand Rub (ABHR) .
Before and after touching residents .
On 10/24/2023 at 9:19 AM Employee Identifier (EI) #4 CNA was observed making RI #81's bed and touching RI #81's bedside table and remote control. EI #4 then, without washing or sanitizing her hands, assisted in making RI #20's bed.
On 10/24/2023 at 9:25 AM EI #4 placed the mechanical lift with the used lift sling, that had been used to transfer RI #81, down the hallway in the education/restorative room without sanitizing the mechanical lift or disposing of the used lift sling. EI #8 CNA pushed the unsanitized mechanical lift and the dirty lift sling up against the wall in the education room and closed the door.
On 10/24/2023 at 10:36 AM EI #6 CNA took the mechanical lift, along with the used lift sling still hanging on the lift, from the education room to RI #3's room. The used lift sling was then placed under RI #3 and the mechanical lift was used by EI #6 and EI #7 to transfer RI #3 to a wheelchair. The unsanitized mechanical lift was then left in the hallway with the used lift sling hanging on the lift.
On 10/24/2023 at 10:44 AM EI #6 CNA wiped the mechanical lift with bleach wipes and left the used lift sling hanging on the lift. EI #7 CNA came and got the lift with the dirty sling and pushed it to RI #19's room.
On 10/24/2023 at 11:01 AM RI #19 was transferred using the mechanical lift then EI #7 cleaned the mechanical lift in the hallway with bleach wipes. EI #7 cleaned part of the mechanical lift, moved the used lift sling to the clean side, and continued to wipe the mechanical lift with the bleach wipes.
On 10/24/2023 at 10:07 AM EI #4 CNA was asked about the lift sling and mechanical lift. EI #4 stated, she did not sanitize the mechanical lift before removing it from RI #81's room or before pushing it into the education room. EI #4 stated, she was supposed to put the lift sling down the laundry shoot. EI #4 stated, she did not have a reason why she did not dispose of the used lift sling and left the lift sling hanging up on the mechanical lift. EI #4 said, the risk of leaving the used lift sling on the mechanical lift was infection control and cross contamination.
EI #4 stated, putting an unsanitized lift and a dirty lift sling in the education room was a risk of cross contamination and infection control issue. EI #4 was asked when she sanitized her hands after caring for RI #81 before assisting with RI #20's bed. EI #4 replied, she did not and and it was a cross contamination and infection control issue.
On 10/24/2023 at 09:51 AM EI #8 CNA asked about the mechanical lift. EI #8 stated, she pushed the mechanical lift up against the wall in the education room. EI #8 stated, the mechanical lift is mostly used for restorative but at times other staff members use the mechanical lift. EI #8 stated, there was a lift sling hanging on the mechanical lift.
On 10/24/2023 at 10:47 AM EI #6 stated, she used the lift sling that was hanging on the mechanical lift. EI #6 stated, after she used the lift sling for RI #3 she put the lift sling back on the lift. EI #6 stated, the lift sling was considered dirty after use and she did not know why she put it back on the lift. EI #6 stated, the residents could get sick and cross contamination from using dirty lift slings.
On 10/24/2023 at 11:15 AM EI #7 CNA stated, she used the lift pad that was already on the lift when she got it out of RI #3's room. EI #7 stated, she should have used a clean lift sling from the linen cart for RI #19. EI #7 stated, when cleaning the mechanical lift and putting the used lift sling on the sanitized area, she would consider the lift contaminated. EI #7 stated, using the dirty lift sling was a risk for infection.
On 10/26/2023 at 8:45 AM an interview was conducted with EI #3 Assistant Director of Nursing (ADON)/Infection Control (IP). EI #3 was asked, after the mechanical lift was used by a staff member for a resident what was the procedure. EI #3 replied, the lift sling should be thrown down to laundry and then the lift wiped down with sanitizing wipes. EI #3 said, lifts should be wiped down before leaving the resident's room. EI #3 stated, taking a lift out of a room that had not been sanitized was a risk of spreading infection. EI #3 stated, after the use of a lift sling staff should put it in a bag and throw it down the laundry shoot. EI #3 stated, touching dirty equipment and not sanitizing hands was a risk for spreading infection. EI #3 was asked, what was the risk of the lift not being cleaned before taking it out of the room. EI #3 replied, the risk of spreading infection. EI #3 was asked, what was the risk of a lift having a dirty sling stored on the lift. EI #3 replied, risk of spreading infection. EI #3 was asked, what was the risk of utilizing a dirty lift sling on different residents. EI #3 replied, risk of spreading infections. EI #3 was asked, when should staff go from making one residents bed and then start touching another residents bed without sanitize or washing their hands. EI #3 stated, never, you should always wash or sanitize hands between residents.
On 10/26/2023 at 10:04 AM an interview was conducted with EI #2 Director of Nursing (DON). EI #2 said, they should clean the lift between uses, after use, and before they come out of the room. EI #2 was asked, what should staff do with the lift sling after use. EI #2 replied, leave under resident or send down to laundry. EI #2 was asked, how should the staff clean the lift. EI #2 replied, sanitizing wipes. EI #2 was asked, what was the risk of using the same lift slings on multiple residents. EI #2 replied, infection control issue. EI #2 was asked, when a staff member went from making one resident's bed to another resident's bed what should they do. EI #2 replied, hand sanitize in between. EI #2 was asked, what was the risk of not washing or sanitizing hands between changing or making different residents beds. EI #2 replied, infection control issue.
Aug 2021
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview, review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION and review of facility policies titled, CONTROLLED SUBSTANCE DISPOSAL and MEDICATION DESTRUCTION FOR NON-CONTROLLE...
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Based on interview, review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION and review of facility policies titled, CONTROLLED SUBSTANCE DISPOSAL and MEDICATION DESTRUCTION FOR NON-CONTROLLED MEDICATIONS, the facility failed to ensure the required number of signatures for destruction of controlled and non-controlled medications were present and documented on the destruction forms.
This affected two of twelve months reviewed for destruction for the year 2020 and three of six months reviewed for the year 2021.
Findings Include:
Review of a facility policy titled, CONTROLLED SUBSTANCE DISPOSAL with a revised date of August 2014 revealed, Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Procedures . E. The (administrator), nurse(s) and/or pharmacist witnessing the destruction ensures that the following information is entered on the (individual controlled substance accountability record/book) . 6) Signatures of witnesses.
Review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION with printed and handwritten dates of 7/2/21 and handwritten times of 1:18 PM and 2:18 PM, for controlled medication, revealed only two of the three required signatures were documented on the forms.
Review of a facility policy titled, MEDICATION DESTRUCTION FOR NON-CONTROLLED MEDICATIONS with a revised date of August 2014 revealed, . Procedures . E. Medication destruction occurs only in the presence of at least two licensed healthcare professionals . F. The licensed healthcare professionals witnessing the destruction ensure that the following information is entered on the (medication disposition form): . 6) Signatures of witnesses.
Review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION with printed and handwritten dates of 10/27/20 for non-controlled medication, revealed only one of the two required signatures were documented on the forms.
Review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION with printed dates of 3/26/21 and 4/6/21, and with handwritten dates of 5/3/21 at 11:55 AM, for non-controlled medication, revealed only one of the two required signatures were documented on the forms.
Review of facility forms CERTIFICATE OF INVENTORY AND DESTRUCTION with printed dates of 8/4/21 for non-controlled medication, revealed only one of the two required signatures were documented on the forms.
On 8/05/21 at 10:31 AM, the CERTIFICATE OF INVENTORY AND DESTRUCTION sheets were reviewed with Employee Identifier (EI) #1, the Director of Nursing (DON). EI #1 was asked how often medications were destroyed. EI #1 replied, it varied. EI #1 was asked how many signatures were on the non-controlled medication destruction sheets. EI #1 replied, only one. EI #1 was
asked how many signatures were required for non-controlled medications. EI #1 replied, two. EI #1 was asked how many signatures were on the controlled medication destruction sheets. EI #1 replied, two. EI #1 was asked how many signatures were required for destruction of controlled medications. EI #1 replied, three. EI #1 was asked why was it necessary to have the required signatures for controlled and non-controlled medication destruction sheets. EI #1 replied, to verify accurate accounts of the medications destroyed. EI #1 was asked what was the facility policy for signatures related to non-controlled medication destruction. EI #1 replied, medication destruction should occur in the presence of two licensed staff. EI #1 was asked what was the facility policy for destruction of controlled medications. EI #1 replied, three verifying and three signatures and if the pharmacist was not in the building it could be the administrator and two nurses.
Nov 2019
3 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of Assure Prism multi Blood Glucose Monitoring System User Instruction Manual, an arti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of Assure Prism multi Blood Glucose Monitoring System User Instruction Manual, an article published by the Centers for Disease Control and Prevention, the [NAME] Alcohol Prep Pad product information, product information for the Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Employee Identifier (EI) #1's Glucometer Sanitizing Skills Validation report, an undated facility document and www.merriam-webster.com, the facility failed to ensure EI #1, a Registered Nurse (RN) cleaned and disinfected the Assure Prism multi Blood Glucose Monitoring System according to the manufacturer's instructions between each resident when she performed finger stick blood sugar testing on Resident Identifier (RI) #64, RI #100 and RI #102 during the evening medication pass observation on 10/30/2019.
After the RN performed RI #102's finger stick blood sugar, she wiped the glucometer with a wet paper towel, then laid the glucometer on the counter beside the sink in the resident's room. The RN did not clean or disinfect the multi-use glucometer per manufacturer's instructions, before she proceeded to check RI #100's finger stick blood sugar. After the RN performed RI #100's finger stick blood sugar, she wiped the glucometer with a [NAME] Alcohol Prep Pad. The RN did not clean or disinfect the multi-use glucometer per manufacturer's instructions, before she proceeded to check RI #64's finger stick blood sugar. After the RN performed RI #64's finger stick blood sugar, she wiped the side, front and top of the glucometer with a [NAME] Alcohol Prep Pad.
This deficient practice affected RI #64, RI #100 and RI #102, three of nine residents observed for finger stick blood sugar monitoring and placed these residents in immediate jeopardy for serious injury, harm, impairment or death. The facility has 48 residents who require finger stick blood sugar monitoring.
On 11/1/2019 at 4:50 PM, the Administrator, Director of Nursing, Director of Operations, Director of Clinical Services and regional Director of Quality Assurance were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Infection Prevention & Control, F 880.
Findings include:
The Assure Prism multi Blood Glucose Monitoring System User Instruction Manual with a revision date of November 2015, documented . Important Safety Instructions: * All parts of the Assure Prism multi Blood Glucose Monitoring System should be considered potentially infectious and is capable of transmitting blood-borne pathogens between patients and healthcare professionals . * The meter should be cleaned and disinfected after use on each patient . Caring for Your System * To minimize the risk of transmission of blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below . Cleaning and Disinfecting: The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens. * The meter should be cleaned and disinfected after each use on each patient . * We have validated Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes1, and PDI Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the Assure Prism multi meter . Cleaning and Disinfecting Procedures: NOTE: Two disposable wipes will be needed for each cleaning and disinfecting procedure; one wipe for cleaning and a second wipe for disinfecting. Cleaning . (3) Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. (4) Dispose of the used towelette in a trash bin. The meter should be cleaned prior to each disinfection step. NOTE: No actual drying of the meter is necessary before starting the disinfecting procedure. Disinfecting (5) Pull out 1 new towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a new towelette to remove blood-borne pathogens. (6) Dispose of the used towelette in a trash bin. (7) Allow exteriors to remain wet for the corresponding contact time for each disinfectant .
During medication pass observation on 10/30/2019 beginning at 3:19 PM, EI #1, a RN pricked the left middle finger of RI #102 to obtain the resident's blood sugar reading. After EI #1 performed RI #102's finger stick blood sugar testing, she wiped the glucometer with a wet paper towel then laid the glucometer on the counter beside the sink in the resident's room.
Without cleaning or disinfecting the multi-use glucometer per manufacturer's instructions, at 4:12 PM, EI #1 proceeded to gather supplies to perform a finger stick blood sugar for RI #100. After the resident's right index finger was pricked to obtain blood for the finger stick blood sugar, EI #1 removed her gloves and wiped the multi-use glucometer with a [NAME] Alcohol Prep Pad.
According to the [NAME] Alcohol Prep Pad, it is a sterile pad that is saturated with 70% volume by volume Isopropyl Alcohol. It is a first-aid antiseptic used for the preparation of the skin prior to an injection.
According to an article published by the Centers for Disease Control and Prevention, titled Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration last updated 8/19/2016, . Blood Glucose Meters . 2. What products are acceptable for cleaning and disinfection of blood glucose meters? . The disinfections solvent you choose should be effective against HIV (Human Immunodeficiency Virus), Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol solutions are not effective against viral bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device .
Without cleaning or disinfecting the multi-use glucometer per the manufacturer's instructions, at 4:28 PM, EI #1 was observed to lay the multi-use glucometer on the over-bed-table of RI #64. After RI #64's left thumb was pricked to obtain blood for the finger stick blood sugar, EI #1 wiped the side, front and top of the glucometer with a [NAME] Alcohol Prep Pad. After the above observations, EI #1 was asked what she cleaned the glucometer with. EI #1 replied she used an alcohol pad ([NAME] Alcohol Prep Pad). EI #1 was asked what she cleaned the glucometer with after she performed RI #102's finger stick blood sugar. EI #1 said she cleaned the glucometer off with a wet paper towel. When asked what she was supposed to use the clean the glucometer, EI #1 answered an alcohol prep pad.
EI #1's Glucometer Sanitizing Skills Validation report indicated on 6/26/2019, EI #1 was observed by EI #3, the Assistant Director of Nursing (ADON) and satisfactorily completed the glucometer sanitizing skills validation tasks.
In a follow-up interview on 10/30/2019 at 5:25 PM, EI #1, RN stated the type of glucometer used was an Assure Prism. EI #1 was asked how many glucometers were on the medication cart. EI #1 answered, there was only one glucometer. When asked if she used the same glucometer on all three residents, EI #1 replied, yes ma'am. EI #1 was asked, what she was supposed to clean and disinfect the glucometer with. EI #1 pointed to the container of Dispatch Hospital Cleaner Disinfectant Towels with Bleach that were located in the bottom drawer of the medication cart. When asked if she cleaned and disinfected the multi-use glucometer between each resident, EI #1 answered no. When asked why she didn't, EI #1 stated she was rushing and didn't see it on the cart. EI #1 was asked, what was the harm in not cleaning the glucometer correctly. EI #1 replied, a patient may be exposed to germs. When asked what the potential for harm was for not disinfecting the glucometer between resident use, EI #1 answered Spreading germs.
The product information for the Dispatch Hospital Cleaner Disinfectant Towels with Bleach indicated it was an Environmental Protection Agency (EPA) registered disinfectant that was recommended for cleaning and disinfecting blood glucose meters and effective against HIV, Hepatitis B and Hepatitis C.
During an interview on 10/31/2019 at 4:23 PM, EI #3, the ADON/Infection Control Nurse was asked who trained the staff on how to clean and disinfect the glucometer. EI #3 said she did. EI #3 was asked how nurses were trained to clean and disinfect the glucometer. EI #3 replied, they are trained to use a bleach-based wipe. EI #3 acknowledged the staff should use a bleach based disinfectant wipe to clean and disinfect the glucometer. EI #3 explained the glucometer should be cleaned before use and after use. EI #3 further stated the glucometer should be disinfected before it is used on another resident. When asked what the potential for harm was for not cleaning and disinfecting the glucometer per the manufacturer's instructions, EI #3 replied cross contamination.
In an interview on 10/31/2019 at 4:39 PM, EI #2, the Director of Nursing acknowledged the nursing staff have been trained to clean and disinfect the glucometer before and after each use. EI #2 stated the Dispatch Hospital Cleaner Disinfectant Towels with Bleach were on the medication carts for the staff to use to clean and disinfect the glucometer. When asked what the potential for harm was for not cleaning and disinfecting the glucometer per the manufacturer's instructions, EI #2 replied it could possibly spread infection.
An undated typed document on facility letterhead indicated 48 residents in the facility required finger stick blood sugar monitoring, of which three residents were diagnosed as having a communicable disease.
A communicable disease, as defined by www.merriam-webster.com, is an infectious disease transmissible by direct contact with an affected individual or the individual's discharges or by indirect means.
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On 11/2/2019 at 10:08 AM, the facility submitted an acceptable Removal Plan, which documented:
November 2, 2019
Removal Plan for F880
1. On October 30, 2019, education was provided to EI#1, the nurse who failed to perform cleaning and disinfecting of the Assure Prism multi use glucometer per manufacturer's recommendation for Resident identifiers #64, #100 and #102. On November 1, 2019 EI #1 provided a return demonstration to the ADON on the cleaning and disinfecting of the Assure Prism multi use glucometer per the manufacturer's recommendations. The Medical Director was informed by the DON on 11/1/19 of the deficient practice involving RI's # 64, #100 and #102. In addition each resident was assessed by the DON/designee on 11/1/19 and no adverse reactions were identified.
2. All licensed staff on duty on today's date, November 1, 2019 have received training by the DON and ADON regarding cleaning and disinfecting of the Assure Prism multi use glucometer according to manufacturer's recommendations. Return demonstrations are being done and will be completed for each licensed staff currently on duty today's date November 1, 2019. Retraining and return demonstrations for all licenses staff who are not on duty will receive training on cleaning and disinfecting the Assure Prism multi use glucometer prior to performing blood glucose monitoring. Date of alleged immediacy removal is 11/1/19.
3. Monitoring of glucometer cleaning and disinfecting return demonstrations on the Assure Prism multi use glucometer began on 11/01/19 by the DON/designee. Monitoring will be for three nurses per shift for one week, then one nurse every shift for two weeks. Thereafter, three nurses will be monitored per week for one month. Monitoring tools will be maintained by the DON.
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After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented by way of observations, staff interviews and record review, the scope/severity level of F 880 was lowered to a D level on 11/1/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of Resident Identifier (RI) #7's medical record and the facility's policy titled Glucos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of Resident Identifier (RI) #7's medical record and the facility's policy titled Glucose Monitoring Equipment - Care and Quality Control Testing, the facility failed to ensure Employee Identifier (EI) #15, a Licensed Practical Nurse (LPN) disposed of a lancet in a Sharps container rather than in RI #7's trash can in the resident's room after she performed a finger stick blood sugar on RI #7 on 10/30/2019. This deficient practice affected RI #7, one of nine residents observed receiving finger stick blood sugars, and performed by EI #15, one of seven nurses observed performing finger stick blood sugars.
Findings include:
The facility's policy titled Glucose Monitoring Equipment - Care and Quality Control Testing, with a revised date of March 2010, documented . PROCESS: I. General Information . c) Disposable lancets and test strips should be discarded in the nearest sharps container .
RI #7 was admitted to the facility on [DATE], with a medical history to include diagnosis of Hyperglycemia.
RI #7's physician orders included an order for . ACCU-CHECKS TWICE A DAY R/T (related to) Diabetes . with an order and start date of 11/20/2018.
On 10/30/2019 at 5:20 PM, EI #15, an LPN was observed performing a finger stick blood sugar on RI #7. EI #15 pricked the resident's finger with a lancet. After obtaining RI #7's blood sugar, EI #15 removed her gloves and placed the gloves and lancet in trash can in RI #7's room.
In an interview on 10/30/2019 at 5:26 PM, EI #15, an LPN was asked where she placed the lancet. EI #15 said in a trash can in RI #7's room. When asked what the potential for harm was with placing a lancet a trash can, EI #15 said someone could get stuck.
During an interview on 11/1/2019 at 7:41 PM, EI #3, the Assistant Director of Nursing (ADON) was asked what the nurse should do with the lancet after a finger blood stick has been performed. EI #3 said the lancet should be placed in the Sharps container. When asked what the potential for harm was with placing a lancet in a trash can, EI #3 said a needle stick could occur.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interviews and review of Employee Identifier (EI) #7's, EI #11's and EI #12's, all Certified Nursing Assistants' (CNAs) employee files, the facility failed to ensure these staff members had t...
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Based on interviews and review of Employee Identifier (EI) #7's, EI #11's and EI #12's, all Certified Nursing Assistants' (CNAs) employee files, the facility failed to ensure these staff members had the required yearly Dementia and/or Abuse training. This deficient practice affected three of 34 employee files reviewed.
Findings include:
EI #7's employee file indicated the CNA had a hire date of 1/13/2014. For the time period 1/13/2018 to 1/13/2019, EI #7 did not receive any Dementia training.
EI #11's employee file indicated the CNA had a hire date of 7/27/2009. For the time period 7/27/2018 to 7/27/2019, EI #11 did not receive any Abuse training.
EI #12's employee file indicated the CNA had a hire date of 6/18/2014. For the time period 6/18/2018 to 6/18/2019, EI #12 did not receive any Dementia training.
In an interview on 10/31/2019 at 5:11 PM, EI #2, the Director of Nursing stated she was not certain why EI #7, EI #11 and EI #12 had not had the required annual Abuse and/or Dementia training. When asked when the CNAs should receive training on Abuse and Dementia, EI #2 said anniversary date to anniversary date.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Alabama facilities.
- • 37% turnover. Below Alabama's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 6 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.
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About This Facility
What is Twin Oaks Rehabilitation And Healthcare Center's CMS Rating?
CMS assigns TWIN OAKS REHABILITATION AND HEALTHCARE CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Alabama, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Twin Oaks Rehabilitation And Healthcare Center Staffed?
CMS rates TWIN OAKS REHABILITATION AND HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 37%, compared to the Alabama average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Twin Oaks Rehabilitation And Healthcare Center?
State health inspectors documented 6 deficiencies at TWIN OAKS REHABILITATION AND HEALTHCARE CENTER during 2019 to 2023. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 5 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Twin Oaks Rehabilitation And Healthcare Center?
TWIN OAKS REHABILITATION AND HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BALL HEALTHCARE SERVICES, a chain that manages multiple nursing homes. With 131 certified beds and approximately 120 residents (about 92% occupancy), it is a mid-sized facility located in MOBILE, Alabama.
How Does Twin Oaks Rehabilitation And Healthcare Center Compare to Other Alabama Nursing Homes?
Compared to the 100 nursing homes in Alabama, TWIN OAKS REHABILITATION AND HEALTHCARE CENTER's overall rating (4 stars) is above the state average of 3.0, staff turnover (37%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Twin Oaks Rehabilitation And Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Twin Oaks Rehabilitation And Healthcare Center Safe?
Based on CMS inspection data, TWIN OAKS REHABILITATION AND HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Alabama. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Twin Oaks Rehabilitation And Healthcare Center Stick Around?
TWIN OAKS REHABILITATION AND HEALTHCARE CENTER has a staff turnover rate of 37%, which is about average for Alabama nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Twin Oaks Rehabilitation And Healthcare Center Ever Fined?
TWIN OAKS REHABILITATION AND HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Twin Oaks Rehabilitation And Healthcare Center on Any Federal Watch List?
TWIN OAKS REHABILITATION AND HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.