Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Rivers Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide written transfer notifications to residents or their representatives for hospital transfers, affecting five residents. The facility's policy did not address the requirement for written notice, leading to incomplete information about transfers. Residents with conditions such as CHF, COPD, dementia, and fractures were transferred without written notifications, and the facility administrator confirmed this practice.
The facility failed to maintain food safety and sanitation standards in the kitchen, affecting all residents consuming food. Observations included improperly sealed food bags, lack of sanitizer in cleaning stations, wet and dirty cups and plates, and potential contamination from dishwashing practices. Kitchen trays also had missing plastic pieces. The District Manager and Administrator expected compliance with policies and standards.
The facility failed to honor residents' rights to hold Resident Council meetings without staff presence, affecting seven residents. Staff were observed at a meeting meant to be closed to them, and residents expressed concerns about the lack of a safe space to discuss issues. The Activity Director was unaware that residents could meet without staff, despite being informed by a resident.
A resident under hospice care received an incorrect dose of Ativan due to an incomplete and improperly documented physician's order. The order was not entered into the EMR, lacked a signature, and had discrepancies with the pharmacy label. This led to the resident experiencing confusion and inappropriate behavior after receiving double the intended dose.
A resident with multiple diagnoses, including gastrostomy status, did not receive tube feeding as ordered by the physician. The feeding pump was observed infusing at an incorrect rate, and an LPN admitted to not always checking the rate. The DON confirmed the necessity of verifying the infusion rate, highlighting a deficiency in the facility's adherence to physician orders.
A facility failed to conduct pain assessments before and after administering PRN narcotic pain medication to a resident with chronic pain syndrome and polyneuropathy. The resident's MAR lacked documentation of pre and post-administration pain levels, which was confirmed by an LPN. The DON expected these assessments to ensure medication effectiveness, but the oversight left the resident at risk for unmanaged pain.
Two residents were affected by the facility's failure to manage medications properly. One resident was prescribed Lorazepam without a stop date, despite being on comfort care, and the medication was administered for agitation. Another resident was given Hydroxyzine HCI for behavior control rather than for itching, as intended. The Medical Director and DON acknowledged the oversight in following regulatory requirements for medication management.
The facility failed to maintain an effective infection control program during wound care for three residents. An LPN and two RNs did not follow proper procedures, such as cleaning surfaces, changing gloves, and using correct wound care techniques. These actions were inconsistent with the facility's policies and professional standards, as confirmed by the DON.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification of transfer to residents or their representatives when residents were transferred to the hospital. This deficiency was identified for five residents who were part of a sample of 25. The facility's policy on Admission, Discharge, and Transfer did not address the requirement to provide written notice, which is a regulatory requirement. The absence of a system for sending written notifications created the potential for residents and their representatives to have incomplete information regarding the transfer, including the reason, location, and appeal rights. For Resident 29, the electronic medical record indicated a transfer to the hospital for evaluation and treatment due to congestive heart failure and chronic obstructive pulmonary disease, but there was no documented evidence of a written transfer notice. Similarly, Resident 36, who was cognitively intact, was transferred to the hospital after a fall and subsequent restlessness, yet did not receive any written paperwork regarding the transfer. Resident 48 was transferred due to a likely fracture, and the family member confirmed not receiving any written notification. Resident 73, who had unspecified dementia and type II diabetes, was transferred to the emergency department due to declining oxygen saturation levels, but the family member only received bed hold notices, not a transfer notice. Lastly, Resident 199, who had a femur fracture and COPD, was transferred after a fall, and the emergency contact was notified verbally, but no written notice was provided. The facility administrator confirmed that written notifications were not provided for transfers.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Several deficiencies were noted in the kitchen, including improperly sealed bags of food in the freezer, such as hamburgers, cookie dough, and dinner rolls. Additionally, the Eco Lab dispenser was not dispensing sanitizer, resulting in the absence of sanitizer in the three-pan sink and red sanitizing buckets. The Dietary Manager had to manually add sanitizer to the sink to achieve the correct concentration. Furthermore, 60 plastic drinking cups and coffee mugs were found wet and not air-dried, and five plastic cups had dried milky substances and food particles inside. Six dirty plates with dried food particles were also found in the plate warmer, ready for use. The survey also revealed that dirty dishes and the dishwasher were located in the same room as clean dishes, leading to potential contamination from the spray used on dirty dishes. Additionally, 32 kitchen trays used for serving meals to residents had missing plastic pieces from the corners and edges. Interviews with the District Manager and the Administrator confirmed their expectations for the kitchen to be fully functional, sanitary, and compliant with policies and standards. These observations indicate a failure to maintain food safety and sanitation standards, potentially affecting all 95 residents consuming food from the kitchen.
Facility Fails to Honor Resident Council Privacy
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in Resident Council meetings without staff presence, affecting seven residents. During a group interview, it was observed that two activity staff and a dietary staff member were present at a Resident Council meeting, which should have been closed to staff unless requested by residents. One resident expressed that she stopped attending the meetings because staff ran them, and it was not a safe space to express concerns about staff. All residents present agreed with this concern. The Activity Director, who had been in her position since December 2023, stated she was told she was required to attend the meetings, although she could not recall who informed her of this requirement. She acknowledged being told by a resident that the meetings should be run by residents and that they did not want staff present. However, she was unaware that residents could hold meetings without staff. The facility administrator expected the facility to follow regulatory requirements to allow residents privacy during these meetings.
Medication Administration Error Due to Incomplete Order Documentation
Penalty
Summary
The facility failed to administer medication according to professional standards of practice for a resident diagnosed with lung cancer under hospice care. The resident was admitted with a physician's order for Ativan Intensol, but the order was undated, untimed, lacked a physician's signature, and was not entered into the Electronic Medical Record (EMR) system. A discrepancy arose when the medication received from the pharmacy had different administration instructions than those initially ordered. The pharmacy label indicated a dosage of 0.5 ml every eight hours, while the physician's order was for 1 ml every six hours. This discrepancy was not clarified before administration. On the night of administration, a Kentucky Medication Aide (KMA) administered 1 ml of Ativan to the resident, which was double the dose indicated on the pharmacy label. This resulted in the resident experiencing confusion, disorientation, and inappropriate behavior. The incident was documented in the resident's progress notes, and a clarification from the physician was obtained the following morning. Interviews with the Director of Nursing and the Medical Director revealed that the order was incomplete and not properly documented, contributing to the administration error.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility staff failed to administer a tube feeding as ordered by the physician for a resident, identified as R51, who was reviewed for tube feeding. This deficiency was identified through observation, interview, and record review. R51 was originally admitted to the facility with multiple diagnoses, including cerebral aneurysm, chronic obstructive pulmonary disease, respiratory failure with hypoxia, gastrostomy status, and tracheostomy status. The physician's orders specified that R51 should receive Glucerna 1.5 calorie at 1210 ml/day at a rate of 55 cc/hour by gastrostomy for 22 hours, along with a 50 cc/hour water flush for 20 hours per day. However, during an observation, it was noted that the tube feeding pump was infusing at a rate of 50 cc/hour, which was not in accordance with the physician's orders. During an interview, an LPN admitted to not always checking the infusion rate to ensure it was correct, although acknowledging that it should be done. The LPN could not recall if the infusion rate was checked that morning. The Director of Nursing confirmed that the nurse should always verify that the enteral feeding pump is set to the rate ordered by the physician. This oversight had the potential to lead to unplanned weight loss for the resident, as the feeding was not administered as prescribed.
Failure to Conduct Pain Assessments for PRN Medication
Penalty
Summary
The facility failed to ensure proper pain management for a resident, identified as R19, by not completing pain assessments before and after administering PRN narcotic pain medications. R19, who was readmitted to the facility with chronic pain syndrome and polyneuropathy, had a care plan that included administering medications as ordered and observing for effectiveness. However, there was no documented evidence of pain assessments being conducted prior to or following the administration of hydromorphone, a narcotic pain medication prescribed to R19 on an as-needed basis. This lack of documentation was confirmed during a review of R19's Medication Administration Record (MAR) for July 2024, which showed no pre or post-administration pain levels recorded. Interviews with R19 revealed that the resident felt the facility could improve in controlling her pain, as she was unaware she could request pain medication every six hours. An LPN confirmed the absence of documented pain assessments in the MAR and stated that such assessments are crucial for managing a resident's pain effectively. The Director of Nursing expressed that it was expected for pain assessments to be conducted before and after administering PRN pain medication to ensure its effectiveness. The facility's failure to adhere to its pain management policy placed R19 at risk for unmanaged pain.
Failure to Ensure Residents Are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications, affecting two residents out of a sample of 25. One resident, identified as R79, was prescribed Lorazepam, a fast-acting antianxiety medication, without a stop date to reassess its necessity. The medication was administered on multiple occasions for agitation, and the Medical Director was unaware that a stop date was required, even though the resident was on end-of-life comfort care. The Director of Nursing acknowledged the need for a stop date for PRN antianxiety medication, even for residents on comfort care. Another resident, R11, was routinely administered Hydroxyzine HCI, an antihistamine, for itching, although it was used to manage behavior rather than for its intended purpose. The resident, who was cognitively intact, did not report itching, and staff confirmed that the resident's scratching was a behavioral response rather than due to itching. The Medical Director admitted to prescribing the medication for behavior control and acknowledged that the order should have been limited to a short duration. The facility's failure to adhere to regulatory requirements for medication management placed residents at risk for unnecessary medication use and potential side effects. The Medical Director and Director of Nursing both recognized the oversight in following proper protocols for prescribing and administering these medications.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during wound care dressing changes for three residents. For Resident 84, the facility did not adhere to proper infection control practices during wound care. The LPN involved did not clean the over bed table before placing a barrier, failed to perform hand hygiene between glove changes, and used improper techniques such as spraying wound cleanser directly into the wound and using a gloved finger to apply ointment. These actions were inconsistent with the facility's policy and professional standards of practice. Resident 19's wound care also demonstrated significant lapses in infection control. The RN did not clean the over bed table before placing a barrier, allowed the privacy curtain to touch the clean barrier, and placed a bottle of wound cleanser on the clean barrier without disinfecting it. Additionally, the RN used the same gloves to clean the wound and apply clean dressings, did not use a circular motion to clean the wound, and failed to date the dressings. The RN also improperly cleaned scissors with soap and water instead of using disinfectant wipes. For Resident 81, the RN did not clean the over bed table before placing a barrier and used the same 4 x 4 gauze to wipe the wound twice without using a different area of the gauze. These actions were contrary to the facility's infection control guidelines. The Director of Nursing confirmed that the observed practices did not align with the facility's policies, highlighting the need for proper cleaning, glove changes, and wound care techniques to prevent contamination and ensure resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Owensboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hermitage Care And Rehabilitation Center | 1.1 mi | ★★★★★ | 3 | 0 |
| Chautauqua Health And Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
| Carmel Home | 2.9 mi | ★★★★★ | 0 | 0 |
| Wellington Parc Of Owensboro | 2.9 mi | ★★★★★ | 7 | 0 |
| Signature Healthcare At Hillcrest | 3.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.