The Estates at Twin Rivers LLC

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident's dignity was maintained when a nephrostomy drainage bag (collection pouch that gathers urine directly from a tube surgically placed in the kidney) was left uncovered and visible from the hallway for 1 of 1 resident (R5) reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain resident equipment in a clean and sanitary manner for 1 of 1 resident (R14) reviewed for a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on interview and document review, the facility failed to ensure a psychotropic medication prescribed on an as-needed (PRN) basis was limited to 14 days, or had documentation from the prescribing practitioner with a rationale for continued use beyond 14 days, for 1 of 5 residents (R19) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide grooming assistance according to a resident's assessed needs and preferences for 1 of 1 resident (R8) reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a nephrostomy drainage system was positioned to allow unobstructed dependent drainage of urine for 1 of 1 resident (R5) reviewed for indwelling catheter care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate infection control practices were performed for 1 of 2 residents (R4) reviewed for installation of eye drops.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 residents (R12) were offered, educated on, and provided the pneumococcal vaccination series as recommended by the Center for Disease Control (CDC), who were reviewed for immunizations.

Inspectors wroteBased on observation and interview, the facility failed to follow established infection control practices for 1 of 3 residents (R4) reviewed for hand hygiene when staff failed to perform hand hygiene and change gloves while performing care.

Inspectors wroteBased on interview and record review the facility failed to prevent a significant medication error for 1 of 1 residents (R1) who was administered ten times the ordered dose of Haloperidol (antipsychotic medication) which resulted in R1 suffering toxic encephalopathy (neurological disorder caused by exposure to toxic agents), sedation, prolonged QT interval (heart takes longer than normal to recharge between beats) and hospitalization. This resulted in an immediate jeopardy (IJ). The IJ began on 10/21/25, when licensed practical nurse (LPN)-A changed R1's order for Haldol from 10 mg to 100 mg without a physician order. The Administrator and Director of Nursing (DON) were notified of the past non-compliance (PNC) IJ on 11/13/25 at 2:55 p.m. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to consistently date fresh and frozen items at the time they were opened, or placed in a container, and failed to remove items which were beyond the acceptable date of use from the refrigerator. The facility also failed to consistently verify the temperatures of freezers were within the desired range to assure food integrity and follow through on the temperatures outside of the desired range. The staff also failed to consistently implement the use of hair nets and beard restraints while preparing and serving food. In addition, food temperature monitoring lacked consistency of completion following food preparation and prior to serving. This had the potential to affect all 32 current residents, as well as staff and visitors who ate the food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure urinary leg bags were effectively secured to prevent falling on the floor and being rolled over by wheelchair for 1 of 1 residents (R28) reviewed for urinary catheter. In addition, the facility failed to conduct ongoing surveillance for the infection control program to ensure tracking and trending of symptomatic illnesses not on antibiotics in the facility. This deficient practice had the potential to affect all 32 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident in 8 of 39 rooms (room #s 4,7,17,20, 21, 29, 35 and 36) which affected seven residents (R144, R92, R27, R5, R192, R21, and R2) who currently resided in these rooms.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications had both open dates and expiration dates marked on the medications so staff new how long the medications were good for. This had the ability to affect all residents on the transitional care unit (TCU) who received medications.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure food served to the residents was palatable, at a pleasing temperature, and in a timely manner for 4 of 4 residents R145, R29, R33, and R93 reviewed for food concerns.

Inspectors wroteBased on observation, interview and document review the facility failed to implement interventions to maintain a dignified appearance related to the failure to properly secure urinary leg bags for 1 of 1 residents (R28) reviewed for urinary catheter.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain proper consent for use of psychotropic medications (a drug which affects behavior, mood, thoughts or perception) for 1 of 5 residents (R35) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the failed to facilitate resident preferences for bathing and meals for 1 of 1 resident (R27) reviewed for choices.

Inspectors wroteBased on observation, interview and document review, the facility failed to consistently provide clean bed linens for 1 of 1 residents (R27) reviewed for choices and provision of assistance with activities of daily living (ADLs).

Inspectors wroteBased on interview and document review, the facility failed to ensure a baseline care plan was developed to ensure all care needs were adequately addressed for 1 of 1 residents (R29) reviewed for range of motion.

Inspectors wroteBased on observation, interview and document review, the facility failed to revise resident care plans with updated interventions for 1 of 1 residents (R27) reviewed for choices and activities of daily.

Inspectors wroteBased on observation, interview and document review the facility failed to provide routine bathing assistance for 1 of 1 residents (R27) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the hospice plan of care had been integrated with the facility care plan for 1 of 1 resident (R35), identified to receive hospice services.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide routine assistance with range of motion (ROM) to to improve strength, mobility and improve circulation of left arm for 1 of 1 (R29) reviewed for ROM.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess and analyze a fall with significant injury for 1 of 2 residents (R11) reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate monitoring for tardive dyskinesia (TD- a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications) was implemented for 1 of 5 residents (R35) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure both recertification survey results, as well as additional complaint investigations, were available for review. This had the potential to affect all 32 residents residing in the facility, as well as family, visitors and staff.

Inspectors wroteBased on interview and document review, the facility failed to provide an individualized care plan for 1 of 3 residents (R1) reviewed for smoking plans.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) reviewed for safe smoking, after R1 was discovered smoking in his room on multiple occasions.

Inspectors wroteBased on interview and document review the facility failed to notify the physician of a significant medication error for 1 of 3 residents (R3) who did not receive prescribed blood pressure medication for five days.

Inspectors wroteBased on interview and document review the facility failed to ensure prescribed blood pressure medication and oxygen was administered for 2 of 3 residents (R3 and R1) reviewed. R3 had an in increase in blood pressure and R1 had an empty oxygen tank and was sent to the emergency room.

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R3) reviewed for quality of care.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide 1:1 supervision during meals to ensure a resident who was identified as a choking risk was supervised while eating for 1 of 3 residents (R2) reviewed for 1:1 supervision during meals.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff implemented the care plan for 1 of 3 residents (R3) when staff failed to reposition and check and change incontinent brief for R3 who required assistance with activities of daily living (ADLs).

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff implemented the care plan for 1 of 3 residents (R3) when staff failed to reposition and check and change incontinent brief for R3 who required assistance with activities of daily living (ADLs).

Inspectors wroteBased on observation, interview and document review, facility failed to practice competent, safe, and sterile technique when administering intravenous (IV) medication via peripherally inserted central catheter (PICC) (enters a peripheral vein and extends to the supervisor vena cava of the heart) 1 of 1 resident (R6) reviewed for medication administration.

Inspectors wroteBased on interview and document review, the facility failed to ensure the services of a registered nurse (RN) were available onsite for 8 consecutive hours seven days a week. This had the potential to affect all 30 residents who reside at the facility. Review of the facility staffing schedules dated 10/1/23 through 12/31/23, identified there was not eight consecutive hours of RN coverage for 10/1/23, 10/8/23, 10/14/23 and 10/15/23. When interviewed 4/24/24 at 8:09 a.m., trained medication aide (TMA)-A stated there were only two licensed nurses employed with the facility which resulted in having to utilize agency licensed nurses. TMA-A stated she was unaware of any day or date when a registered nurse was unavailable for eight consecutive hours and verified a licensed nurse was always on duty. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident in 8 of 39 rooms (room #s 4,7,17,20, 21, 29, 35 and 36) which affected nine residents (R1, R187, R12, R16, R5, R23, R18, R6 and R27) who currently resided in these rooms.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R21), reviewed and observed for self-administration of medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure reasonable accommodation of need related to repositioning device for 1 of 1 resident (R21) reviewed for bed rails.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure room temperature and refrigerated food items were properly stored, labeled, and dated when the original packaging was opened. This deficient practice had the potential to affect all 36 residents who ate food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain sanitary conditions in the kitchen. This had the potential to affect all 36 residents who ate food prepared in the kitchen.