Twin Cedar Senior Living

Staff A was hired before their criminal background check was completed.

Staff person B did not receive required training in fall and accident prevention during the 2024 training year.

The 2025 staff training plan lacked proposed training dates and instructor information.

Resident MM was provided a thickened liquid diet instead of the prescribed pureed diet.

An unannounced fire drill was not held during the month of February 2025.

During fire drills on 8/23/24 and 11/6/24, one resident failed to evacuate to the designated meeting place.

The initial Medical Evaluation form for resident #1 did not indicate whether the resident is able to self-administer medications.

The home is not connected to a public water source and has been testing positive for Coliform since the last water test on 5/22/2024.

The home has been using paper plates, plastic cups, and plastic utensils on a regular basis since 11/28/2023.

Resident Assessment Support Plans for two residents did not reflect specific needs, intended use, or risks associated with bedside mobility devices.

Frozen uncooked pie crust and pretzel rolls were stored in unsealed bags in the freezer.

Frozen pie crust and pretzel rolls in the freezer were not dated.

A sock was found behind the dryer in the laundry room, posing a potential fire hazard near a heat source.

During a fire drill, a staff member pushed a resident on a rollator walker, causing the resident to fall and sustain a fractured right ankle.

The home failed to provide the proper equipment necessary to allow safe movement and exiting from the home for a resident with a disability.

An unwitnessed fall resulting in a head hematoma was not reported to the Department within 24 hours.

Trash, including an empty creamer container and bug spray, was left outside near the kitchen door.

A chair in the resident library had a broken back, posing a safety hazard.

A partially used bag of Penne pasta was stored in the dry storage area without being securely closed.

Two boxes of muffin mix in the dry storage area were not dated upon receipt.

Cigarette butts were found on the ground outside the kitchen door in a non-smoking home.

Resident did not begin prescribed Keflex medication until two days after the prescribed start date.

The resident's support plan did not reflect the podiatrist's orders for specific wound care treatments for a left heel wound.

The resident did not sign their support plan following their participation in its development.