Twin Rivers Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 28, 2025

  Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure residents were free of harm due to improper transferring of residents with a mechanical lift for one (Resident #1) of one resident reviewed for transfers. Resident #1 had a negative outcome which resulted in a right distal third spiral femur fracture (a spiral fracture line caused by twisting forces). The findings include: Review of an “admission Record,” indicated the facility admitted Resident #1 on 07/03/2012 with diagnoses which included brain damage due to lack of oxygen, blocked blood flow to the brain, anxiety disorder, sudden burst of electrical activity in the brain (seizures), weakened bones, cognitive communication deficit, contracture of left hand,… […]

• No harm, potential for more than minimal, widespreadF812Feb 12, 2026

  Number of residents sampled: Number of residents cited: Based on observation, record review and interview, the facility failed to ensure foods stored in freezers were covered and sealed to maintain freshness and decrease the potential for cross contamination. The facility also failed to ensure the low temperature dishwasher was maintained at proper temperatures to prevent potential contamination of dishware. This failed practice had the potential to affect 67 residents who received meals from the kitchen. The findings include: Incident #1 During the initial tour of the kitchen and concurrent interview with the Dietary Manager (DM) on 02/09/2026 at 10:20 AM, the following were observed: -An opened pie crust that did not have an open date or use by date in the pantry area. […]

• No harm, potential for more than minimal, widespreadF812Oct 20, 2023

  Based on observation, record review and interview, the facility failed to ensure foods stored in in the freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; dish washer walls, baseboard, and wallboard were free of stain, debris, dirt, and rust; door frames and baseboards were free of chipped areas; wall tiles and baseboard were replaced, staff washed their hands between dirty and clean tasks and before handling clean equipment or contamination; and hot food items were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. […]

• No harm, potential for more than minimal, widespreadF812Jul 15, 2022

  Based on observation and interview the facility failed to ensure food stored in the refrigerator and freezer was tightly sealed, dishes were properly sanitized by immersion in either hot water (at least 171 F) for 30 seconds; or a chemical sanitizing solution (chlorine: ,d+[DATE] ppm minimum 10 seconds contact time), and the ice machine were maintained in clean sanitary condition to minimize the potential the potential food borne illness for residents who receive meals and ice from the kitchen and food items brought in by visitors were monitored for expiration dates for 1 of 1 resident (Resident #39). The failed practices had the potential to affect 61 residents who receive meals from the kitchen (total census 64:), as documented on a list provided by the dietary manager on [DATE]. […]

• No harm, potential for more than minimal, patternF812Aug 29, 2024

  Based on observation and interview, it was determined the facility failed to keep food at a safe temperature prior to serving residents. The findings are: On 8/28/2024 at 7:31 AM, [NAME] #1 checked the temperature of the foods on the steam table using a probe thermometer. The temperature of the pureed eggs was 125 degrees. On 8/28/2024 at 11:52 AM, [NAME] #1 was asked what the temperature of the food held on the steam table should be. [NAME] #1 said between 175 and 185 (degrees Fahrenheit). [NAME] #1 said the steam table hasn't been working correctly and that 2 of the compartments had quit working. On 8/28/2024 at 11:59 AM, the Dietary Manager (DM) was asked what temperature should the food on the steam table be held at prior to serving the residents. The DM said 180 degrees. […]