Twin Oaks Health & Rehabilitation Center

Penalties

• Jan 18, 2024 — Fine ($174,431)

Inspection findings

1. Dec 31, 2025 Health · 12 findings
   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jan 5, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Jan 5, 2026 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Jan 5, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

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

     Corrected Jan 5, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Jan 5, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

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

     Corrected Jan 5, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jan 5, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jan 5, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Jan 5, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jan 5, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

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

     CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Jan 5, 2026 · CMS fire safety

2. Apr 15, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0622 Resident Rights Deficiencies

     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.

     Corrected May 4, 2025 · CMS health inspection

3. Sep 25, 2024 Health · 19 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

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

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0887 Infection Control Deficiencies

     Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0919 Environmental Deficiencies

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

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0924 Environmental Deficiencies

     Put firmly secured handrails on each side of hallways.

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0926 Environmental Deficiencies

     Have policies on smoking.

     Corrected Sep 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

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

     Corrected Oct 18, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Oct 18, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Oct 18, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Oct 18, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

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

     CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Oct 9, 2024 · CMS fire safety

4. Jan 18, 2024 Health · 3 findings
   • Serious Scope/severity J Complaint

     F0580 Resident Rights Deficiencies

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

     Corrected Jan 19, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Jan 19, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Jan 19, 2024 · CMS health inspection

5. Oct 29, 2023 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Sep 14, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Sep 14, 2023 · CMS health inspection

6. Jul 26, 2023 Health · 12 findings
   • Not serious Scope/severity D

     F0585 Resident Rights Deficiencies

     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.

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

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

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

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

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Aug 18, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

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

     Corrected Sep 1, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

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

     CMS fire safety

Owners and managers (as published by CMS)

• BLAKE, GARY — adp of the snf, NOT APPLICABLE, since 04/01/2022
• BLAKE, GARY — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• BLAKE, MALISA — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• FREGIA, MILTON — managing control - governing body, NOT APPLICABLE, since 05/07/2022
• GARDNER, SHANNON — managing control - governing body, NOT APPLICABLE, since 08/22/2022
• GARDZINA, MARGARET — managing control - governing body, NOT APPLICABLE, since 02/26/2024
• HEKIMIAN, KHOREN — adp of the snf, NOT APPLICABLE, since 04/11/2025
• HENRY, PAUL — managing control - governing body, NOT APPLICABLE, since 05/09/2009
• HUGGINS, LINDA — corporate director, NOT APPLICABLE, since 04/01/2022
• STRATTON, CHARLES — managing control - governing body, NOT APPLICABLE, since 05/01/2005
• STRATTON, CHARLES — corporate officer, NOT APPLICABLE, since 05/01/2005
• WILLIAMSON, ROSE — adp of the snf, NOT APPLICABLE, since 04/11/2025
• WILLIG, ZACHARY — corporate director, NOT APPLICABLE, since 01/01/2025
• JACKSONVILLE III ENTERPRISES LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2022
• JACKSONVILLE III ENTERPRISES LLC — adp of the snf, NOT APPLICABLE, since 04/11/2025
• LIBERTY COUNTY HOSPITAL DISTRICT NO 1 — 5% or greater direct ownership interest, 100%, since 04/01/2022