Inspection Report Summary
The most recent inspection on July 18, 2025, found the facility in substantial compliance with no deficiencies cited. Earlier inspections also showed a consistent pattern of meeting regulatory requirements without notable issues. There were no complaint investigations reported or enforcement actions listed in the available reports. The facility appears to maintain compliance with applicable standards over time. This suggests a stable regulatory history without emerging concerns.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than Kentucky average
Kentucky average: 4.7 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Census: 96
Deficiencies: 0
Date: Jul 18, 2025
Visit Reason
A Standard Recertification and Abbreviated Survey was conducted to assess the facility's compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B, and no regulatory deficiencies were issued during this survey.
Report Facts
Sample Size: 20
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 18, 2025
Visit Reason
The inspection was conducted as an annual survey of Twin Rivers Nursing and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected are unknown.
Inspection Report
Routine
Deficiencies: 8
Date: Jul 26, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, transfer notifications, medication administration, feeding tube care, pain management, use of psychotropic medications, food service safety, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to private Resident Council meetings, failure to provide written transfer notifications to residents or their representatives, medication administration errors, improper feeding tube management, inadequate pain assessment documentation, inappropriate use of psychotropic medications, food service sanitation issues, and poor infection control practices during wound care.
Deficiencies (8)
Failed to ensure Resident Council meetings were held without staff present, violating residents' right to autonomy.
Failed to provide written notification of hospital transfers to residents or their representatives for 5 residents.
Medication administration error: Resident received double dose of Ativan due to incomplete and unsigned telephone order.
Failed to administer tube feeding as ordered, with feeding pump set at incorrect rate.
Failed to complete pain assessments before and after PRN narcotic pain medication administration.
Failed to implement gradual dose reductions and limit PRN use of psychotropic medications; Lorazepam ordered without stop date for comfort care resident; Hydroxyzine used for behavior control without appropriate indication.
Failed to store, prepare, distribute, and serve food in accordance with professional standards; issues included unsealed frozen foods, sanitizer not dispensing, wet cups stored without air drying, dirty dishes in plate warmer, cross contamination of clean and dirty dishes, and damaged kitchen trays.
Failed to follow infection prevention and control guidelines during wound care dressing changes for three residents, including improper cleaning of equipment and surfaces, failure to change gloves appropriately, improper wound cleansing technique, and failure to date dressings.
Report Facts
Residents reviewed for Resident Council rights: 25
Residents affected by Resident Council deficiency: 7
Residents reviewed for emergency transfers: 25
Residents affected by transfer notification deficiency: 5
Ativan dose administered: 2
Ativan received from pharmacy: 30
Tube feeding rate ordered: 55
Tube feeding rate observed: 50
Lorazepam administration dates: 3
Hydroxyzine administration exceptions: 6
Plastic drinking cups observed: 60
Plastic cups with dried residue: 5
Dirty plates observed: 6
Kitchen trays with plastic pieces missing: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN3 | Registered Nurse | Signed order for Ativan and confirmed dosage with physician |
| KMA1 | Kentucky Medication Aide | Administered incorrect dose of Ativan to Resident 81 |
| AD | Activity Director | Ran Resident Council meetings despite residents' objections |
| Administrator | Stated expectation for privacy in Resident Council meetings and medication administration protocols | |
| DON | Director of Nursing | Commented on medication order incompleteness and pain assessment expectations |
| RN1 | Registered Nurse | Performed wound care with multiple infection control failures |
| RN2 | Registered Nurse | Performed wound care with infection control deficiencies |
| LPN1 | Licensed Practical Nurse | Admitted to not always checking feeding pump rate |
| LPN2 | Licensed Practical Nurse | Performed wound care with infection control failures |
| LPN4 | Licensed Practical Nurse | Confirmed lack of pain assessment documentation |
| CNA4 | Certified Nursing Assistant | Reported no complaints of itching from Resident 11 |
| CNA5 | Certified Nursing Assistant | Reported no complaints of itching from Resident 11 |
| Medical Director | Reviewed medication orders and commented on stop dates and prescribing practices | |
| Dietary Manager | Verified food service sanitation deficiencies | |
| District Manager | Stated expectations for kitchen sanitation and functionality |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 5, 2019
Visit Reason
The inspection was a routine survey to assess compliance with federal and state regulations related to resident rights, facility maintenance, resident assessments, care planning, provision of care, and safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity (staff entering rooms without knocking), inadequate maintenance of the environment (damaged tiles, peeling paint, clogged sinks), inaccurate resident assessments, incomplete and inaccurate care plans, failure to provide oral care and assistive devices, improper catheter care, and inadequate pain management.
Deficiencies (10)
Staff entered residents' rooms without knocking, violating residents' rights to dignity and privacy.
Facility failed to provide maintenance services to maintain a safe, clean, and homelike environment including cracked tiles, peeling paint, and clogged sinks.
Facility failed to ensure six residents received accurate assessments reflective of their status, including coding errors related to hospice services, oral/dental status, and pressure ulcers.
Facility failed to develop comprehensive care plans for oral/dental care for two residents.
Facility failed to revise care plans to include adaptive equipment for eating for four residents.
Facility failed to provide care according to written plans for four residents, including oral care, assistive devices for eating, pain assessment, and catheter care.
Facility failed to provide oral care daily for three residents who were unable to perform oral hygiene independently.
Facility failed to provide appropriate catheter care for one resident, including improper positioning of catheter tubing and drainage bag.
Facility failed to provide assistive eating devices for one resident as required by care plan.
Facility failed to ensure nurse assessed and evaluated resident's pain prior to administering pain medication and failed to inform resident of medication given.
Report Facts
Sampled residents: 32
Residents affected: 2
Residents affected: 3
Residents affected: 6
Residents affected: 4
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Entered residents' rooms without knocking |
| NA #2 | Nurse Aide | Responsible for oral care, admitted not always completing it |
| NA #3 | Certified Nurse Aide | Served meal trays, failed to ensure assistive devices were on tray |
| NA #4 | Certified Nurse Aide | Failed to ensure assistive devices on meal trays |
| LPN #2 | Licensed Practical Nurse | Monitored care, acknowledged failure to assess pain and improper catheter care |
| RN #1 | Registered Nurse | Administered pain medication without assessing pain or informing resident |
| Director of Nursing | Director of Nursing | Provided statements on expectations for care, assessments, and monitoring |
| Assistant Director of Nursing | Assistant Director of Nursing | Monitored residents and care plans, provided statements on care expectations |
| Maintenance Director | Maintenance Director | Provided statements on maintenance priorities and repairs |
| Administrator | Administrator | Provided statements on facility maintenance and remodeling plans |
| Dietary Manager | Dietary Manager | Responsible for updating care plans with assistive devices |
| Interim Dietary Manager | Interim Dietary Manager | Acknowledged failure to add assistive devices to meal trays |
| Certified Nurse Aide #8 | Certified Nurse Aide | Monitored catheter tubing positioning |
| Certified Nurse Aide #5 | Certified Nurse Aide | Described proper catheter tubing positioning and lack of education |
| Wound Care Nurse | Wound Care Nurse | Assessed resident's pain during wound care |
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