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PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.



Based on observation; interview; record review; review of the facility policy, Fall Investigation, and Incident Report; and review of the hospital emergency room (ER) record, Discharge Summary and Radiology Report; it was determined the facility failed to ensure adequate supervision to prevent accidents for two (2) of five (5) sampled residents (Residents #1 and #4).

The facility failed to have an effective system in place to ensure Resident #1 received adequate supervision while ambulating and toileting. The facility readmitted Resident #1 on [DATE]. Licensed Practical Nurse (LPN) #8 failed to conduct the fall assessment per facility instructions. Resident #1 was care planned for one (1) person physical assist while ambulating and toileting. Interviews with staff revealed Resident #1 had difficulty walking, continuously got out of bed without asking for assistance, and would exit the bathroom into the wrong room and at times was found in another room, on the bed. However, staff failed to use the facility’s Stop and Watch form to make licensed staff aware of the resident’s actions to ensure Resident #1 had adequate supervision when ambulating. On [DATE] at approximately 11:15 PM, Resident #1 was found in an adjacent room (Room #106) at approximately 11:38 PM, on the floor. Resident #1 was transferred to the hospital ER where he/she was admitted to the hospital with [REDACTED]. Resident #1 died in the hospital on [DATE]. Refer to F280

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We can help you and your loved one file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

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  1. nunya says:

    This place is a shit hole, my grandmother stayed there n it was horrible. Needs to be shut down

  2. Marcia says:

    My Mother was in this same home and in the same room. She has now passed.She to suffered from neglect. This nursing home is very under staffed. And some of the aids didn’t like there jobs, you could tell by their attitudes.

    • kim givens says:

      I believe they all are Severely under staffed. I knew a women who loved the people she was caring for but she was stressed because she didn’t have enough time to care for each one properly, so she began to come in 2 hours early off the clock which led to the termination of her job.

  3. Debra Allen says:

    Why is this place even still open? I worked there in the past. I seen hands on what how’s on there and it has for years. This place has had numerous violation from way back when it wasBon Harbor. The name changed but the neglect and abuse continues. When is the state of My going to stick up for the elderly and close those doors for good? How many more have to die?

    • Justin says:

      I wouldn’t mind to read your comment, but it is horribly constructed. In fact, to the point that it makes absolutely no sense! Judging by your grammar, spelling, and punctuation, I am sure you were a great employee! Smh…

  4. Angela says:

    My best friend is in this place now it’s always clear smells nice most of the employees are very nice we have had very few problems there but she is able to talk and take care of self in most ways

  5. pam pollock says:

    My friend died there, she went through hell being in pain,,I called the state they check her records couldn’t find nothing to get them on,,well I hope to hell now the state shuts that hell place down.

  6. Workinggirl says:

    I have worked here for more than ten years and I love the place. There are many caring and loving workers that do their best to ensure that the residents are taken care of. No nursing home is perfect. Accidents do happen, they can happen in your own home. People shouldn’t pass judgement on things that they don’t have all of the facts on. “Judge not lest ye be judged”

    • Sarah says:

      I call bullshit!!! No first hand they have hired jus random kids to have a staff n agree moat them hate their jobs. The article speaks for itself!

    • Jennifer harris says:

      You are very right!! I have family members that work there now and in the past, I also worked there many years ago. And I know they all work hard and love their patients. Give it granted at times they are under staffed but so are most nursing homes we can only do so much and it hurts us when one of our patients get hurt or anything. Keep up the good work and thanks for all you do

  7. Tell it like it is says:

    It is a very sad thing that happened but you can find that it happens in other nursing homes as well I have had family members that was in there and they all have passed away and trust me on this they was well taken care of.Also I worked there as well you have to actually work in a nursing home before you pass judgment they work hard and they are always short staffed in all nursing homes.If you could have done it any better than you should have done it yourself

    • To whom it concerns says:

      Agreed, we work our butt off to do everything we can, and state regs say alot of facilities are over staffed according to their guidelines. And its all about the Benjamin’s when it comes to staffing. And if a company can cut cost to save money and state backs them up well, what can you do. We just work there. But, you have to realize most of us love our residents they are our 2nd family and sometimes we see them more than our own families. I work as a CNA in another nursing home and they are right no nursing home is perfect by far but, we do the job that no one else wants to do, and then we take the blame for when someone thinks it should be done differently or better. It’s in the health care feild and a chance you take when you choose this career.
      I’m not defending all situations because some places should be shut down because of abuse and neglect. But, I am in agreement with don’t judge by what you hear unless you know all the facts.

    • Christine says:

      Thank you. I am a nurse in a nursing home in Ohio and you really hit home. Anyone that wants to try being a nursing aide come on because we could use the help.

  8. Pam says:

    I’m not ready to pass judgment on this nursing home. To me it seems impossible to constantly supervise one patient who is clearly no longer in a clear state of mind without neglecting all the other patients. It does sound like it might have been understaffed. But can the patients afford the additional charges that would result from hiring many more staff members? It sounds like the patients should have been in an Alzheimer’s facility–very expensive!

  9. The Truth Hurts says:

    Worked at this nursing home its one of the worst to be at and work at. Caused me nothing but problems. There are a handful of great employees who go above and beyond for residents and co workers the rest there are no words for.

  10. Jessica Waltrip says:

    I worked in Nursing homes for over 30 years. Before you blame the home you need to understand that the state is not on them for the death. they are on them for not having the paper work in order,,,If the facility had paper proof that all of the steps had been taken to ensure the residents safety they would not cite them. The death of the resident would have been unfortunate but not held against the facility as they had proof they tried the best they could….

  11. Cindy says:

    If so many of you people are going to pass judgement and find faults with this long term facility and you have loved ones there. I suggest you take them home and take care of them yourselves. That way you can no longer pass judgement on these hard working individuals that work diligently to care for your loved ones.BUT they can not by any means control the behaviors or the outcomes which may arise. They are NOT GOD, and can not predict what YOUR family member may do next. They work hard to keep them safe each and every day.

  12. Murphy says:

    If you have a resident that often gets up and walks on their own even though they should not because they are not always physically able to but they have dementia and do not realize it they are going to fall unless you have someone there 24 hours sitting there waiting for them to get up. Staff are busy caring for people and are not just waiting for someone to deciede they want to take a walk. The families should take them home if that is there expectations. Maybe when the nursing home has a resident that frequent falls they should suggest to family to place them elsewhere. Of course that might cause a burden to the families that might have to drive a little further or whatever else the reason may be to put your loved one in a home that your unsatified with.The problem is not all nursing homes our under staffed. What do you want them to do employee a staff member to sit with the people that are at risk for falls one on one? I can garantee they will fall at home if they were staying in the daughter or sons home as well. You can come up with solutions to prevent as much as possible but FALLS are going to happen even in the best of nursing homes.

  13. Debra Allen says:

    Has anyone took a minute and actually read the 8 pages listed? Seriously? Read them and more on the abuse sites that are public record for this place.From not admi istering proper care after accidents to medicine not on carts that belong to clients but logged as administered etc etc..And you do not see me using g a fake name do you? I k ow what I wittnesssed at that pla e I have no reason to hide my name. It should of been shutdown years ago!

  14. Concerned says:

    If anyone chooses to help, write to your legislators. State law only requires TWO nurse’s aides to an entire section of patients. With the mentally challenged this is so NOT enough. If someone calls in sick, they are then short 1 aide. If they bother to borrow an aide from a different section then this aide doesn’t know the patients. While our Mother is not at this nursing home, the one she is in, has borrowed or had so many new ones, can’t seem to keep them, even their borrowed nurses or temp nurses do not know our Mother is not suppose to walk even with an aide. Our nursing homes are a mess. May this person RIP.

  15. George Gibbs St says:

    I presume a lot of this is out of context, but I also know from first hand that most home are under stated. This all comes back to the cost and the dollar. Regulations and signs need to be placed on doors giving the circumstances of each patient. Maybe surveillance camera’s for the nursing or person in charge can review what happens. It is easy to blame the staff and Co workers, but it almost impossible to predict what are resident will do in the next 15 minutes. Maybe more support and awareness needs to be supported more by everyone including family.

  16. I tsee says:

    I have worked in the health care for over 30 years and you can’t watch every one at the same time. While I was still working in the nursing home the state was only wanting to know if the paperwork was done they don’t look at patients care. So don’t judge all nurses and nursing aids they go above and beyond.

  17. Helen Evans says:

    My sister stayed and passed away in that rest home and I saw first hand how hard they worked to give good care to the patients. I visited a lot and I have no complaints about the care she received. She wasn’t happy to be there but who would be?

  18. Nayla Dunn says:

    I took care of my mother for over five years with dementia and almost blind with macular degeneration and there was no way I could have prevented her falls and she fell a lot. We tried to keep the things in the same place to help prevent most people from falling but due to dementia she could not remember so she fell. She is now in a long term care facility. I have been in long term care nursing for over 38 years. I think everyone should try taking care of their love one a while before they complain about the place that the person is living and then if you aren’t happy then take them somewhere else.

  19. Pamela Harper Baird says:

    My father has been in this facility for over a year. I can’t come up with a single complaint regarding his care. The staff are awesome! I too worked as a CNA for years and know what goes on “behind the scenes.” I couldn’t give my dad any better care at home. The key to a successful long term experience is, be aware! Don’t drop your loved one off as if it were an animal shelter! Visit them frequently. Even if they can’t communicate, you can get to know the staff yourself. Get a feel of what goes on, see it for yourself. If your not comfortable with what you see, say something! If you’re not happy with the results, you have the right and responsibility to move your loved one. YOU are their biggest advocate! I certainly hope the staff at Twin Rivers knows how much I personally appreciate them. They are doing for my dad the things I can’t do myself!


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