Twin Rivers Nursing and Rehabilitation Center

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to issue the resident or their representative a written notification of transfer when the resident was transferred to the hospital for five (5) of five (5) sampled residents reviewed for emergency transfers out of a total sample of 25 residents, Resident (R)29, R36, R48, R73, and R199. The facility did not have a system in place for sending written notification of transfer to residents or their representatives. This created the potential for the resident and/or their representative to have incomplete information related to the reason for transfer, location of transfer and/or how to appeal the transfer, if desired.

Inspectors wroteBased on observation, interview, and review of facility policies, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures had the potential to affect all 95 residents in the facility who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Resident Council's right to have their group meeting without staff present was honored and promoted for seven (7) of seven (7) residents reviewed for Resident Council resident rights out of a total sample of 25 residents, Resident (R)6, R12, R21, R38, R54, R56, and R63. This failure violated the residents' right to autonomy and to be able to bring up concerns without staff present.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure medication was administered according to professional standards of practice for one of 25 sampled residents, Resident (R) 81. This failure placed R81 at risk for inappropriate behavior, confusion, and disorientation.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to administer a tube feeding as ordered by the physician for one (1) of two (2) residents reviewed for tube feeding out of a total sample of of 25 residents, Resident (R) 51. This failure had the potential for unplanned weight loss.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure pain assessments were completed prior to and after the administration of PRN (as needed) narcotic pain medications for one (1) of two (2)sampled residents reviewed for pain management out of 25 sampled residents, Resident (R)19. R19 was ordered and administered pain medication; however, there was no documented evidence pre or post pain assessments were completed to measure if the medication was effective to ensure the resident's pain was being managed. This failure placed the resident at risk for a decreased quality of life related to uncontrolled pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for two (2) of six (6) residents reviewed for unnecessary medications out of a total of 25 sampled residents, Resident (R)79 and R11. This failure placed both residents at risk for side effects such as drowsiness and sedation. R79 was ordered Lorazepam (fast-acting antianxiety medication) with no stop date to reevaluate the medical necessity of the medication. Additionally, R11 was ordered and routinely administered Hydroxyzine HCI (an antihistamine medication) for itching; however, the medication was being used to control the resident's behavior.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow infection control guidelines and facility policy during wound care dressing changes for three (3) of three (3) residents reviewed for wound care out of a total sample of 25 residents, Resident (R) 84, R19, and R81.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure six (6) of thirty-two (32) sampled residents received an accurate assessment, reflective of the resident's status at the time of the assessment (Residents #2, #49, #93, #42, #83, and #50). The facility failed to code the Minimum Data Set (MDS) assessment accurately for Resident #50 related to receiving Hospice Services; Residents #2 and #49 related to Oral/Dental Status; and, Residents #42, #83 and #93 related to pressure ulcer or diabetic foot ulcers.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure Comprehensive Care Plans were revised for four (4) of thirty-two (32) sampled residents (Residents #9, # 17, #79, and # 81). The facility assessed Residents #9, #17, #79, and #81 to require the use of adaptive equipment for eating; however, review of the care plans revealed there was no documented evidence the care plans were updated to include the adaptive equipment.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to provide care in accordance with each resident's written plan of care for four (4) of thirty-two (32) sampled residents (Resident #104, #65, #83 and #100). The facility failed to implement the Comprehensive Care Plan for Resident #104 related to oral care. Resident #65 related to assistive devices for eating. Resident #83 related to pain assessment; and, Resident #100 related to catheter care.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for two (2) of thirty-two (32) sampled residents (Residents #60 and #45). Observations on 03/05/19 revealed staff entered Resident #45's and #60's rooms without knocking on the door prior to entering.

Inspectors wroteBased on observation, interview, and review of facility's policy, it was determined the facility failed to provide maintenance services necessary to maintain an orderly, comfortable, and homelike interior in three (3) of sixty-four (64) residents' rooms. Observations, of room [ROOM NUMBER], on 03/05/19 revealed tiles in the bathroom that were uneven, cracked, and chipped, brown stained areas in the ceiling, and gouged and scraped wood trim along the walls. Further observation revealed large areas of peeling paint particles hanging from the wall. In addition, a storage cabinet in the room had multiple areas of chipping paint. Observation on 03/06/19, revealed a totally clogged sink in room [ROOM NUMBER]; and, room [ROOM NUMBER] had a slow running drain.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy it was determined the facility failed to develop a comprehensive person-centered care plan for (2) of thirty-two (32) sampled residents (Resident #2, and #49). The facility failed to develop a Comprehensive Care Plan for oral/dental care for Residents #2 and #49.

Inspectors wroteBased on observation, interview, record review and review of Mosby's Textbook for Long Term Care Nursing Assistants, it was determined the facility failed to ensure a resident, who was unable to carry out activities of daily living (ADL's), received the necessary services to maintain oral hygiene for three (3) of thirty-two (32) sampled residents (Residents #2, #49 and #104). The facility failed to provide oral care daily for Residents #2, #49 and #104.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident, with an indwelling catheter, received the appropriate care and services to prevent urinary tract infections to the extent possible for one (1) of thirty-two (32) sampled residents (Resident #100). Three (3) observations revealed improper positioning of Resident #100's urinary catheter tubing and drainage bag placement.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the nurse who gave pain medication to the resident assessed and evaluated a resident's pain characteristics such as intensity, pattern, location, frequency, and duration prior to administering pain medication according to professional standards of practice, for one (1) of thirty-two (32) sampled residents (Resident #83). In addition, the nurse failed to make the resident aware of what medication was being administered (Oxycodone).

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide assistive devices for one (1) of thirty-two (32) sampled residents (Resident #65). Observations on 03/05/19 at 11:03 AM, on 03/06/19 at 8:36 AM, and on 03/07/19 at 8:32 AM, revealed Resident #65 did not receive his/her foam built up fork and spoon to enable the resident to feed self.