The Estates At Twin Rivers Llc
THE ESTATES AT TWIN RIVERS LLC in ANOKA, MN — inspection on November 13, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
medication dosage, notify the physician or pharmacy to follow-up.
Notify physician, family, and nurse leadership immediately for medication errors and initiate orders to begin monitoring for adverse reactions to medication discrepancy.
The PNC IJ that began on 10/21/25, was removed on 11/10/25, when it was verified, the facility implemented the following: -suspended on 11/7/25, and subsequently terminated LPN-A, the nurse who transcribed the order. -review of all residents on antipsychotic and psychotropic medications to ensure accuracy was completed on 11/7/25. -education provided to nursing staff on medication administration and transcription double check of orders completed on 11/10/25. -review by DON/designee daily of all orders discontinued and initiated into the order system began 11/7/25. -competency for psychotropic medications and side effects for nursing staff completed on 11/10/25. -reviewed policies and procedures related to medication administration and transcription double check, pharmacy, change of condition, and medication errors on 11/7/25.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.