Twin City Health Care

In the surveyor’s words

From the most serious findings on record at Twin City Health Care, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Sep 17, 2024

  Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 by not wearing appropriate personal protective equipment (PPE) in areas requiring transmission-based precautions (TBP) during random observations on the 100 and 200 halls. Findings include: During a random observation, on 9/11/24 at 11:29 a.m., Housekeeper 3 was seen entering and exiting room [ROOM NUMBER] while wearing gloves and a surgical mask. Signage on the door indicated the residents were in TBP and a gown, gloves, face shield and mask were required before entering the residents' room. During an interview, at the time of observation, Housekeeper 3 indicated she didn't need to wear a face shield, as she wore glasses. She only needed to wear gloves and a surgical mask. […]

• No harm, potential for more than minimal, patternF759Sep 25, 2023

  Based on observation, interview, and record review, the facility failed to ensure a medication (insulin) was administered according to professional standards for 5 of 41 residents (Residents 8, 9, 22, 11, and 19), resulting in a medication administration error rate of 12.2%. Findings include: On 9/22/23 at 6:45 am, during a medication administration observation with the DON, she administered 2 units of insulin aspart to Resident 8. She did not prime the pen needle before administration, and held the pen in the resident's left upper arm for less than 3 seconds before withdrawing the needle. During an interview, on 9/22/23 at 6:50 a.m., the DON indicated it was her practice to hold the needle in the injection site for 2 to 3 seconds. […]

• No harm, potential for more than minimal, patternF759Jul 2, 2021

  Based on observation, interview, and record review, 44 opportunities of medication administration were observed and 4 of the 44 medications were not administered in accordance with physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: During a medication administration observation on 7/1/21 at 8:02 a.m., the following was observed: QMA 24 prepared polyethylene [MEDICATION(S)] (laxative) powder for Resident 19 by measuring approximately 30 mL of powder in a medication cup. She poured the powder into a cup of liquid and mixed it. She indicated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/1/21 at 8:11 a.m., LPN 33 prepared a [MEDICATION(S)] (long acting insulin) pen for Resident 12 to inject 15 units. […]

• No harm, potential for more than minimal, patternF804Jul 2, 2021

  Based on observation, interview, and record review, the facility failed to serve appetizing and palatable meals to residents. Findings include: During a Resident Council interview, on 6/29/21 at 1:35 p.m., the council attendees indicated the facility food was overcooked, mushy and unappetizing. They had to eat a lot of peanut butter and jelly sandwiches, chicken noodle soup, and lunchmeat and cheese sandwiches instead of the meals due to the poor quality of the food. They served a lot of mashed potatoes. They felt supper was the worst, and they frequently ordered out, which got to be expensive and not everyone could afford to. If they did ask for seconds of a food item, they were frequently told they had run out of food. […]

• No harm, potential for more than minimal, isolatedF628Aug 14, 2025

  Based on interview and record review, the facility failed to ensure residents or their representatives were provided with bed hold policies prior to hospitalization for 3 of 4 residents reviewed for hospitalization. (Residents 11, 19, and 25) Finding includes:1.Resident 11's clinical record was reviewed on 8/12/25 at 8:31 a.m. Diagnoses included unspecified dementia, schizophrenia, and delusional disorder.A quarterly, Minimum Data Set (MDS) assessment, dated 5/1/25, indicated the resident interview was unable to be completed.The clinical record lacked information regarding who received the bed hold policy when the resident was transferred to the hospital on 6/22/25.2.Resident 19's clinical record was reviewed on 8/12/25 at 8:39 a.m.Diagnoses included type two diabetes, chronic kidney… […]