The Estates at Twin Rivers LLC

In the surveyor’s words

From the most serious findings on record at The Estates at Twin Rivers LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Nov 13, 2025

  Based 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. […]

• Actual harm, isolatedF686Mar 9, 2021

  Based on interview and document review, the facility failed to provide pressure ulcer care per physician orders, and notify the physician when they were unable to provide the ordered wound care for 1 of 2 residents (R2) reviewed who had pressure ulcers. This resulted in actual harm for R2 when the pressure ulcer deteriorated, became infected, and R2 was hospitalized for [REDACTED]. Findings include: R2's 5 day PPS Minimum Data Set ((MDS) dated [DATE], included cognitively intact, required extensive assistance with bed mobility, transfers and hygiene. R2 had 5 stage 4 pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. […]

• No harm, potential for more than minimal, widespreadF812May 23, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880May 23, 2025

  Based 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. Findings include: R28's admission Minimum Data Set (MDS) dated [DATE], indicated R28 had moderate cognitive impairment and required assistance with activities of daily living (ADL's) including dressing, grooming, bathing, and transfers. […]

• No harm, potential for more than minimal, widespreadF912May 23, 2025

  Based 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. Findings include: During the entrance conference on 5/19/25 at 11:34 a.m., the facility administrator stated there had been no changes in resident room sizes, and there were waivers in place for room numbers: 4,7,17, 20, 21, 29,35, and 36 which did not meet the required minimum square footage. The following double resident rooms did not meet the required minimum square footage per resident: room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident (empty). […]