Twin Pines North Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Twin Pines North Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Oct 7, 2022

  Based on observation, interview and record review, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. LVN A did not check that the crash cart did not have the defibrillator. 2. LVN A stopped CPR after 30 minutes (7:45 PM-8:15 PM) because of wrong information they received from the Hospice Nurse at 8:15 PM. 3. LVN B brought a crash cart to R#1's room but forgot to bring the AED; and the resident was not hooked to the defibrillator. LVN B stopped CPR at the directions from LVN A at 8:15 PM 4. LVN C assumed LVN A called 911. LVN C did not check that the defibrillator was not present. LVN C stopped CPR at the directions from LVN A at 8:15 PM. 5. […]

• No harm, potential for more than minimal, patternF812Jun 5, 2026

  Based on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Kitchen 1) and 2 of 3 Serveries (Servery 2 and Servery 3) reviewed for food safety requirements.1. Three bulk bin lids in the kitchen for flour and cornmeal were cracked with sharp edges and gaps are not easily cleanable and could let contaminants into the bin.2. Food service staff in Servery 2 and Servery 3 stored items in the hand sink and trash cans in front making them inaccessible for use on 6/2/2026. 3. Reach in refrigerator read 51 degrees F on the digital thermometer and milk read 53.7 degrees F in Servery 3 on 6/2/2026.4. […]

• No harm, potential for more than minimal, patternF880Jun 5, 2026

  Based on observation, interview, and record review, the facility failed to 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 disease and infection for 4 of 7 residents (Residents #5, #10, #63 and, #92) reviewed for infection control, in that: 1. The facility failed to ensure Resident #5 who had a wound was placed on enhanced barrier precaution. 2.The facility failed to ensure LVN C changed her gloves to prevent cross contamination while providing wound care for Resident #10 3. The facility failed to ensure CNA D sanitized or washed her hands between changing gloves while providing incontinent care for Resident #63. 4. […]

• No harm, potential for more than minimal, patternF677Dec 18, 2025

  Based on interview, and record review, the facility failed to provide a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Resident #1 and Resident #4), reviewed for the ADL of showers/bathing. 1.Resident #1 did not receive showers/bathing for the period 11/18/25 to 11/29/25 (11 days). 2.Resident #4 did not receive showers/bathing for the period 12/01/25 to 12/15/25 (14 days). […]

• No harm, potential for more than minimal, patternF842Dec 18, 2025

  Based on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented for 2 of 4 (Residents #1 and #4) residents reviewed for accuracy of clinical records. There were no Nurse Notes in the EMR documenting that Resident #1's and Resident #4's missed or refused showers/bathing. This failure could result in inadequate care due to incomplete and inaccurate medical records. The findings include: 1.Record review of Resident #1's face sheet, dated 12/27/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged home on [DATE]. Resident #1 had diagnoses which included: HTN (hypertension), kidney disease, a UTI (urinary tract infection at admissions), and a history of stroke. […]