Twin Oaks Assisted Living and Memory Care.
Twin Oaks Assisted Living and Memory Care is Ranked in the bottom 11% of Utah memory care with 11 DLBC citations on record; last inspected Dec 2025.
A large home, reviewed on public record.
Compared to 35 Utah facilities with a similar number of beds.
Care · 36-month window. Higher percentile = better performance on inspection record. Source: Utah Dept. of Health & Human Services · Division of Licensing and Background Checks.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · BETA
Twin Oaks Assisted Living and Memory Care has 11 citations on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
11 deficiencies on record. Each bar is a month with a citation.
Finding distribution
11 total · 36 monthsScope × Severity (CMS A–L)
Every DLBC visit, verbatim.
12 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-12-08Annual Compliance VisitNo findings
2025-05-13Complaint InvestigationNo findings
2025-04-28Complaint InvestigationNo findings
2025-03-20Complaint InvestigationModerate · 1 finding
Plain-language summary
During this annual inspection, the facility was found to have medication administration violations, including one resident who did not receive a medication as prescribed and five staff members who administered medications without proper delegation from a licensed healthcare professional. Both issues represent repeat noncompliance, with the delegation problem previously cited in January 2025 and the prescribing order issue recurring since August 2024. These findings indicate ongoing problems with how the facility manages medication safety and oversight.
“The Licensee was out of compliance with R432-270-19(7)(d) by not ensuring medications were administered according to the prescribing order. During the inspection, a medication was not administered according to the prescribing order for 1 resident. This is a repeat noncompliance from the inspections dated August 13, 2024, October 28, 2024, and January 29, 2025.”
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[R432-270-19(7)(a)-(f)] The Licensee was out of compliance with R432-270-19(7)(d) by not ensuring medications were administered according to the prescribing order. During the inspection, a medication was not administered according to the prescribing order for 1 resident. This is a repeat noncompliance from the inspections dated August 13, 2024, October 28, 2024, and January 29, 2025. [R432-270-19(7)(a)-(f)] The Licensee was out of compliance with R432-270-19(7)(b) by not ensuring facility staff administered medications only after delegation by a licensed health care professional under the scope of their practice. During the inspection, it was noted that 5 facility staff administered medications without delegation by the current licensed health care professional. This is a repeat noncompliance from the inspection dated January 29, 2025.
2025-01-29Annual Compliance VisitModerate · 4 findings
Plain-language summary
During this annual inspection, the facility was found out of compliance in four areas, all involving repeat violations from prior inspections. The facility failed to report a resident's unexplained injury as a critical incident within one business day, did not investigate or report the injury to Adult Protective Services or police despite suspected abuse, administered medications to two residents without proper delegation from a licensed healthcare professional and not according to prescribing orders, and did not complete drug testing for six staff members after discovering that narcotic medications had been tampered with for multiple residents. These findings represent ongoing failures in resident safety, medication management, and incident reporting.
“The provider was out of compliance with this rule by not ensuring that when a critical incident occurred, the facility submitted a report of the critical incident to the office in the format required by the office within one business day of the critical incident occurrence. During the inspection, 1 resident had an injury of unknown origin and a critical incident was not reported to the office within 1 business day. This is a repeat noncompliance from the inspection dated 10/28/2024.”
“The provider was out of compliance with this rule by not ensuring the administrator completed an investigation when there was reason to believe a resident had been subject to abuse and reported any suspected abuse in accordance with Section 62A-3-305. During the inspection, it was noted that 1 resident had an injury of unknown origin that was not investigated and was not reported to Adult Protective Services or the local police. This is a repeat noncompliance from the inspections dated 3/27/2024 and 12/4/2024.”
“The provider was out of compliance with this rule by not ensuring (b) facility staff administered medications only after delegation by a licensed health care professional under the scope of their practice and (d) ensured medications were administered according to the prescribing order. During the inspection, it was noted that 2 facility staff administered medications without delegation by the licensed health care professional and medications were not administered according to the prescribing order for 1 resident. This is a repeat noncompliance from the inspections dated 8/13/2024 and 10/28/2024.”
“The provider was out of compliance with this rule by not ensuring residents were protected from harm, mistreatment, and any action that compromised the health and safety of residents through acts or omissions. During the inspection, it was noted that after discovering a large number of narcotic medications had been tampered with for multiple residents', the facility reported staff were drug tested as part of the correction plan; 6 staff were not drug tested per the correction plan. This is a repeat noncompliance from inspections dated 8/13/2024 and 10/28/2024.”
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[R380-600-7(16)(a)-(d)] The provider was out of compliance with this rule by not ensuring that when a critical incident occurred, the facility submitted a report of the critical incident to the office in the format required by the office within one business day of the critical incident occurrence. During the inspection, 1 resident had an injury of unknown origin and a critical incident was not reported to the office within 1 business day. This is a repeat noncompliance from the inspection dated 10/28/2024. [R432-270-8(1)(a)-(p)] The provider was out of compliance with this rule by not ensuring the administrator completed an investigation when there was reason to believe a resident had been subject to abuse and reported any suspected abuse in accordance with Section 62A-3-305. During the inspection, it was noted that 1 resident had an injury of unknown origin that was not investigated and was not reported to Adult Protective Services or the local police. This is a repeat noncompliance from the inspections dated 3/27/2024 and 12/4/2024. [R432-270-19(7)(a)-(f)] The provider was out of compliance with this rule by not ensuring (b) facility staff administered medications only after delegation by a licensed health care professional under the scope of their practice and (d) ensured medications were administered according to the prescribing order. During the inspection, it was noted that 2 facility staff administered medications without delegation by the licensed health care professional and medications were not administered according to the prescribing order for 1 resident. This is a repeat noncompliance from the inspections dated 8/13/2024 and 10/28/2024. [R380-80-5(4)] The provider was out of compliance with this rule by not ensuring residents were protected from harm, mistreatment, and any action that compromised the health and safety of residents through acts or omissions. During the inspection, it was noted that after discovering a large number of narcotic medications had been tampered with for multiple residents', the facility reported staff were drug tested as part of the correction plan; 6 staff were not drug tested per the correction plan. This is a repeat noncompliance from inspections dated 8/13/2024 and 10/28/2024.
2024-12-04Annual Compliance VisitSerious · 1 finding
Plain-language summary
During an annual inspection, the facility was found to have failed to report a suspected abuse allegation to Adult Protective Services or local police as required by state law. The administrator did not comply with the mandatory reporting requirement under Utah Code Section 62A-3-305. This noncompliance with R432-270-8(1)(a)-(p) represents a failure in the facility's abuse reporting procedures.
“The provider was out of compliance with this rule by not ensuring the administrator reported any suspected abuse in accordance with Section 62A-3-305. During the inspection, it was noted that one allegation of suspected abuse was not documented to have been reported to Adult Protective Services or the local police.”
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[R432-270-8(1)(a)-(p)] The provider was out of compliance with this rule by not ensuring the administrator reported any suspected abuse in accordance with Section 62A-3-305. During the inspection, it was noted that one allegation of suspected abuse was not documented to have been reported to Adult Protective Services or the local police.
2024-10-28Annual Compliance VisitSerious · 2 findings
Plain-language summary
During this annual inspection, the facility was found out of compliance with regulations protecting residents from neglect and mistreatment, including a case where a resident alleged mistreatment by a staff member who was allowed to continue providing care without protective action, and a situation involving missing narcotic medications where not all staff members were drug tested as required. The facility was also cited for administering medications to at least one resident that did not match the prescribing order. Both violations indicate failures in resident protection and medication safety protocols.
“The provider was out of compliance with this rule by not ensuring residents were protected from neglect, mistreatment, and any action that compromised the health and safety of residents through acts or omissions. During the inspection, 1 resident was noted to have alleged neglectful behavior and mistreatment from a staff member; no actions were taken to protect the resident, and the staff member was allowed to continue providing care to the resident. Additionally, after discovering a large number of a resident's narcotic medications were missing, the facility reported staff were drug tested as part of the correction plan; 2 staff were not drug tested per the correction plan.”
“The provider was out of compliance with this rule by not ensuring medications were administered according to the prescribing order. During the inspection, it was noted that medications were not administered according to the prescribing order for 1 resident.”
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[R380-80-5(4)] The provider was out of compliance with this rule by not ensuring residents were protected from neglect, mistreatment, and any action that compromised the health and safety of residents through acts or omissions. During the inspection, 1 resident was noted to have alleged neglectful behavior and mistreatment from a staff member; no actions were taken to protect the resident, and the staff member was allowed to continue providing care to the resident. Additionally, after discovering a large number of a resident's narcotic medications were missing, the facility reported staff were drug tested as part of the correction plan; 2 staff were not drug tested per the correction plan. [R432-270-19(7)(a)-(f)] The provider was out of compliance with this rule by not ensuring medications were administered according to the prescribing order. During the inspection, it was noted that medications were not administered according to the prescribing order for 1 resident.
2024-08-13Complaint InvestigationSerious · 1 finding
Plain-language summary
During this inspection, investigators found that the facility failed to protect residents from abuse, neglect, and harm as required by state rules. One resident had an injury of unknown origin that the facility did not properly investigate or address, and two other residents were identified as alleged abuse victims whom the facility did not adequately protect or report on. The facility was cited for noncompliance with protections required under Utah Admin. Code R380-80-5(4).
“The provider was out of compliance with this rule by not ensuring clients were protected from abuse, neglect, harm, and mistreatment and any action that may have compromised the health and safety of clients through acts or omissions and did not instruct and encourage others to do the same. During the inspection, 1 resident was identified as having an injury of unknown origin and the provider did not ensure the resident was protected from any action that may have compromised their health and safety. Additionally, 2 residents were identified as alleged victims of abuse and the provider did not protect them and did not instruct and encourage others to do the same.”
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[R380-80-5(4)] The provider was out of compliance with this rule by not ensuring clients were protected from abuse, neglect, harm, and mistreatment and any action that may have compromised the health and safety of clients through acts or omissions and did not instruct and encourage others to do the same. During the inspection, 1 resident was identified as having an injury of unknown origin and the provider did not ensure the resident was protected from any action that may have compromised their health and safety. Additionally, 2 residents were identified as alleged victims of abuse and the provider did not protect them and did not instruct and encourage others to do the same.
2024-07-29Annual Compliance VisitNo findings
2024-06-26Annual Compliance VisitNo findings
2024-05-30Annual Compliance VisitNo findings
2024-03-27Complaint InvestigationStandard · 2 findings
Plain-language summary
During this annual inspection, the facility was found out of compliance with recordkeeping requirements because one incident report listed in the log could not be located, and records were not properly filed or stored to remain accessible to staff and the department. The facility also failed to conduct adequate investigations into reported incidents of abuse or neglect, including an allegation that was reported to the Department where the investigation contained inconsistent information that was not pursued, and a resident injury of unknown origin that had no investigation or incident note completed.
“The provider was out of compliance with this rule by not ensuring accurate and complete records were maintained. The licensee did not safely file and store records and did not ensure they remained easily accessible to staff and the department. During the inspection, 1 incident report noted in the incident report log was not available for review.”
“The provider was out of compliance with this rule by not ensuring the administrator completed an investigation when there was reason to believe a resident had been subjected to abuse or neglect. During the inspection, the licensor reviewed the administrator's investigation of an abuse allegation incident that had been reported to the Department. The investigation contained incongruous pieces of information that were not investigated that were relevant to the final determination of the abuse accusation. The licensor also observed on the incident report log, a resident was reported to have sustained an injury of unknown origin. The administrator stated the incident listed on the report log did not have an incident note attached to it and no investigation was completed.”
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[R432-270-21(1)] The provider was out of compliance with this rule by not ensuring accurate and complete records were maintained. The licensee did not safely file and store records and did not ensure they remained easily accessible to staff and the department. During the inspection, 1 incident report noted in the incident report log was not available for review. [R432-270-8(1)(a)-(p)] The provider was out of compliance with this rule by not ensuring the administrator completed an investigation when there was reason to believe a resident had been subjected to abuse or neglect. During the inspection, the licensor reviewed the administrator's investigation of an abuse allegation incident that had been reported to the Department. The investigation contained incongruous pieces of information that were not investigated that were relevant to the final determination of the abuse accusation. The licensor also observed on the incident report log, a resident was reported to have sustained an injury of unknown origin. The administrator stated the incident listed on the report log did not have an incident note attached to it and no investigation was completed.
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