Twin City Health Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 disease stage three, and depression.An admission MDS assessment, dated 7/2/25, indicated the resident was cognitively intact.A progress note, dated 8/5/25 at 3:45 p.m., indicated the resident was transferred to the hospital for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to appropriately date opened insulin pens for 2 of 4 medication carts observed for medication storage. (A Unit cart and C Unit cart) This had the potential to affect 6 of 6 residents who received insulin from A Unit and C Unit carts.Findings include:During a medication storage observation of the A Unit cart, accompanied by QMA 3, on [DATE] at 3:48 p.m., the following was observed: one Basaglar (insulin) 3 milliliters (ml) Kwikpen 100 units per ml, with the seal broken and the pen undated, with approximately 150 units used and one Basaglar 3 ml KwikPen 100 units per ml, with the seal broken and the pen undated, with approximately 75 units used.During a medication storage observation of the C Unit cart, accompanied by QMA 3, on [DATE] at 4:06 p.m., the following was observed: one Lantus (insulin) 3 milliliters (ml) KwikPen 100 units per ml, with the seal broken and then pen undated, with approximately 200 units used.During an interview on [DATE] at 4:11 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. During a random observation, on 9/12/24 at 2:08 p.m., Housekeeper 3 entered a positive COVID-19 resident's room while wearing a gown and gloves. Signage on the door indicated the resident was on TBP and everyone must wear a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications given by gastrostomy tube (G-tube) were administered according to physician's orders and facility policy for 1 of 7 residents observed for medication administration, resulting in an 8.89 % medication error rate. (Resident 31) Finding includes: During an observation, on 9/13/24 at 10:19 a.m., LPN 4 removed the stopper from Resident 31's G-tube, flushed the G-tube with 30 ml (milliliters) of water, and administered multiple medications one at a time via G-tube. The medications included escitalopram (antidepressant) 20 mg tablet crushed mixed with 20 ml water, multivitamin crushed mixed with 20 ml water, linezolid (antibiotic) 600 mg crushed and mixed with 20 ml water, and docusate sodium (50 mg/5 ml) 10 ml. Auscultation of an air bolus and a check for residual stomach contents was not performed prior to the medication administration. During an interview, immediately following the medication administration, LPN 4 indicated the resident took all medications via G-tube. Placement for the G-tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. On 9/22/23 at 6:53 a.m., the DON administered 30 units of insulin detemir to Resident 9. She did not prime the needle before administration, and held the needle in place for less than 2 seconds. On 9/22/23 at 7:00 a.m., the DON administered 14 units of insulin lispro to Resident 22. She did not prime the needle before administration, and immediately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's code status was correctly listed and readily available in the resident's electronic medical record (EMR) for 1 of 16 residents reviewed for advance directives (Resident 83). Finding includes: Resident 83's record was reviewed on [DATE] at 3:49 p.m. Diagnoses included left and right femur fractures, chronic obstructive pulmonary disease, abnormal electrocardiogram, acute respiratory failure with hypoxia, and chronic atrial fibrillation. Her physician's orders included code status DNR (do not resuscitate) initiated on [DATE]. A Code Status/Advance Directives form indicated the resident did not want to have CPR (cardiopulmonary resuscitation) performed as a life-saving measure. The form, signed by the resident on [DATE], was in the paper chart. The face sheet in the EMR lacked her code status. The Continuity of Care record in the EMR indicated, under the Advance Directives section, No Advance Directives are on file for this resident.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency for 1 of 1 resident-to-resident altercations reviewed for abuse (Resident 9 and 26). Finding includes: During an interview, on 9/20/23 at 9:35 a.m., Resident 9 indicated another resident had hit her several months ago. She no longer went near the other resident because of the altercation. Resident 9's clinical record was reviewed on 9/20/23 at 3:40 p.m. Her diagnoses included paranoid schizophrenia, bipolar disease, major depressive disorder, recurrent, anxiety disorder, and pseudobulbar affect. An 8/8/23 quarterly Minimum Data Set (MDS) assessment indicated she was cognitively intact and had exhibited no behaviors during the assessment period. She utilized a walker and a wheelchair for mobility and was independent with locomotion off and on the nursing unit. A care plan for false allegations against staff, initiated 11/15/22 and last revised on 8/23/23, indicated the resident had a history of making false allegations against staff regarding care or lack of care, abuse, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure narcotic medication was free from diversion for 1 of 3 residents reviewed for misappropriation of resident property (Resident B). Findings include: Resident B's clinical record was reviewed on 8/14/23 at 2:47 p.m. Diagnoses included encounter for palliative care, anxiety disorder, chronic obstructive pulmonary disease, dependence on supplemental oxygen, and chronic pulmonary edema. His current medications included morphine concentrate 0.25 ml (milliliter) every two hours as needed for shortness of breath or pain. Review of a Consolidated Delivery Sheet indicated, on 9/23/22 at 11:15 p.m., the pharmacy delivered a 30 ml bottle of morphine sulfate 100 mg/5 ml and it was signed for by a nurse at the facility. Review of the resident's MARs (Medication Administration Records) indicated the following: In September 2022, he was not administered morphine for the entire month. In October 2022, he was administered morphine 0.25 ml on 10/31/22. In November 2022, he was not administered morphine for the entire month. In…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to report misappropriation of a resident's property related to missing morphine to law enforcement and to the Indiana Department of Health (IDOH) for 1 of 3 residents reviewed for misappropriation of property (Resident B). Findings include: During an interview with the Administrator, on 8/14/23 at 1:03 p.m., she indicated she received a call, not an allegation, from QMA 4 about Resident B's bottle of morphine, there was thought to be two bottles of morphine but only one was in the narcotic drawer. It was investigated, they looked for the bottle and couldn't see where he had two bottles. Education was provided to the staff and she came up with a form to count cards and bottles. During an interview with QMA 4, on 8/14/23 at 2:09 p.m., she thought there were two bottles of morphine but she wasn't 100% sure, she reported it to management. She did a narcotic count in the morning with RN 8, there was only one bottle but thought there had been two bottles, when she counted with LPN 15, in the evening, LPN 15 also thought there had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.