Twin Pines Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF755Jun 8, 2021

  Based on observation, interview and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medications for 21 of 22 residents (Residents #3, #5, #8, #11, #14, #15, #27, #30, #37, #39, #54, #56, #57, #60, #70, #73, #76, #86,#94, #195, and #247) reviewed for pharmacy services. 1. Resident #3 missed 3 doses of her medication, calamine lotion, for itching, 5 doses of her medication, [MEDICATION(S)] 40mg, for [CONDITION(S)], 3 doses of her medication, [MEDICATION(S)] 5mg, for [CONDITION(S)] of knee, 7 doses of her medication, [MEDICATION(S)] AF cream 1%, for fungal infection, 1 dose of her medication, [MEDICATION(S)] extended release 500mg, for [CONDITION(S)], 11 doses of her medication,… […]

• Immediate jeopardy, patternF835Jun 8, 2021

  Based on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 facility reviewed for administration, in that: The Administrator and DON did not monitor to follow-up on missed medications administered to 21 residents (Residents #3, #5, #8, #11, #14, #15, #27, #30, #37, #39, #54, #56, #57, #60, #70, #73, #76, #86,#94, #195, and #247) by facility nursing staff. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 06/04/2021. […]

• Immediate jeopardy, isolatedF656Jul 13, 2025

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 2 of 5 residents (Residents #1 and #2) reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan with interventions to address Resident #1's behavior of unbuckling the seat belt when transported in the facility van. […]

• Immediate jeopardy, isolatedF689Jul 13, 2025

  Based on interviews and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 2 residents (Residents #1 and #2) reviewed for accidents. 1. The facility failed to identify and address hazards and risk in Resident #1's environment when staff failed to ensure they addressed Resident #1's behavior of unbuckling the seatbelt during transport in the facility van. On 06/13/2025, Resident #1 sustained a fall during van transport, with the seat belt noted to be on the wheelchair but the fastener unlatched, resulting in a laceration to her forehead. 2. […]

• Immediate jeopardy, isolatedF689Nov 15, 2024

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #1 who eloped from the facility on 06/21/24. The noncompliance was identified as PNC. The IJ began on 06/21/24 and ended on 06/22/24. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. […]