Twin Pines Adult Care Center

Inspectors wroteBased on observation, interview, and record review, facility staff failed to treat three residents (Resident #5, #7, and #8) in a review of ten sampled residents, with respect and in a manner that maintained their dignity. The facility census was 73. Review of the facility's Dignity and Respect policy, undated, showed the following:-Every resident has a right to be treated with dignity and respect;-All staff will speak to and treat all residents with dignity and respect. 1. Review of Resident #8's Face Sheet, undated, showed the following:-The resident was readmitted on [DATE];-The resident was his/her own responsible party;-Diagnoses included dementia, muscle wasting and atrophy (wasting, shrinkage, or decrease in size of body tissues, muscles, or organs, typically resulting in reduced function), anxiety disorder (fear of or apprehension about real or perceived threats). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide each resident with meals served at an appetizing temperature for four residents (Residents #2, 3, 4, and 7) out of ten sampled residents. The facility census was 73. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party when one resident (Resident #9) of ten sampled residents, had medication changes and transfer to a hospital. The facility census was 73. Review of the facility's Notification of Changes Policy, dated 5/2021, showed the following:-It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority;-Notification is provided to residents and/or the resident representative(s) to promote the resident's right to make choices about care and treatment and to keep them informed of the resident's current health status. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to have a grievance procedure with an identified person to lead investigations, a system to inform residents of their right to file a grievance, and documentation to show the results of grievance investigations for six of six residents (Resident (R) 1, R21, R28, R38, R48, and R56) interviewed in the resident group interview. The failure had the potential to affect all residents who resided at the facility to be informed of their right to file a grievance and for the facility to resolve any grievance the residents may have.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food stored in the kitchen was labeled and dated with an open date to ensure opened food items were discarded in a timely manner. This had the potential to increase the spread of foodborne illnesses for 72 out of 72 residents that receive meals from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure that five of five employee files reviewed had the required Quality Assurance and Performance Improvement (QAPI) training. This failure had the potential to have a negative impact on staff for their unawareness about how to bring concerns to QAPI and in return this could impact the 72 residents currently residing at the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that three of five employee files (Certified Nursing Assistant (CNA) 6, CNA7, and CNA1) reviewed had a background check prior to hire. This had the potential to have staff hired that have an unknown history of abuse.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure three of three residents (Resident (R) 21, R41, and R2) reviewed for hospitalization out of a total sample of 22 and their representatives were given a written notice of transfer to the hospital. In addition, the Ombudsman was not notified of the monthly hospitalizations. This failure created the potential for residents or their responsible party not to have the information needed to understand their transfer to the hospital.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure three of three residents (Resident (R) 21, R41, and R2) reviewed for hospitalization out of a total sample of 22 residents were given a written copy of a bed hold notice within 24-hours of emergency transfer to the hospital. This failure created the potential for residents and/or responsible parties not to have the information needed to safeguard their return to the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure three residents (Resident (R) 1, R23, and R24) out of 22 sampled residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner. This failure has the potential of non-payment for necessary resident care.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure three of five Certified Nursing Assistants (CNA)1, CNA6, and CNA7) completed the minimum of 12 hours of in-service training per year. The lack of in-service training could have a negative impact on all 72 residents currently residing at the facility by the staff not knowing how to care for the residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents who self-administered medications had a self-administration of medications assessment, a physician's order, and a care plan completed for two of two residents (Resident (R) 4 and R44) reviewed for self-administration of medications out of a total sample of 22 residents. Failure to assess and care plan residents for self-administration of medications increases the potential of medication errors for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the physician follow up information on a skin condition for one resident (Resident (R) 45) delaying treatment and failed to assess the need to crush medications for one resident (R5) out of a total sample of 22 residents. These failures increased the risk that residents would not receive timely and/or effective treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents' (Resident (R) 4) call light was present and functioning. This failure had the potential to restrict residents from calling for assistance while using the restroom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution. The facility census was 67. Observations on 01/24/23 between 8:50 A.M. and 9:14 A.M. showed the following: -Dietary Aide prepared food in the kitchen. He/She had a beard and was not wearing a beard restraint; -Dietary Aide Y prepared food in the kitchen. His/Her hair was not completely covered with a hairnet, the sides of his/her hair hung out from under the hairnet; -The dietary manager prepared food in the kitchen. His/Her hair hung out from under his/her hairnet and was not completely covered. Observation on 1/24/23 at 8:58 A.M., showed a heavy brown/black buildup on the inside of the convection oven. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the comprehensive care plans for four residents (Residents #10, #24, #30, and #48) in a review of 21 sampled residents. The facility census was 67. Review of the facility's undated policy, Comprehensive Resident Centered Care Plans, showed the following: -It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident; -The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational and environmental needs as appropriate; [...]

Inspectors wrote7. Review of Resident #10's care plan, revised 11/21/22, showed the following: -He/She was independent for transferring; -The resident was independent for repositioning and turning in bed; -Bed rail as needed or desired for increased mobility and transfers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was moderately impaired; -He/She had diagnoses of non-traumatic brain dysfunction and dementia; -He/She was independent with bed mobility. Review of the resident's physician's order sheet showed no orders for a bed rail. Observation on 1/26/23 at 9:18 A.M. showed the following: -The resident lay in his/her bed with his/her eyes closed; -The resident's bed had 1/4 bed rails on both sides of the bed; -The head of the bed was elevated and the resident's bed rail located closest to the door was in the raised position. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired stock medication from the medication room and medication carts, failed to date an open insulin vial for one resident (Resident #22), and failed to keep medications secured when staff left a medication cart unlocked and unattended in a hallway when passing medications. The facility census was 67. Review of the facility's policy, Destruction/Returning of Discontinued Medications, dated [DATE], showed the following: -Purpose: To assure discontinued medications are either destroyed in a timely manner or returned to the pharmacy; -Resident medications that have been discontinued by the physician shall be either destroyed on the premises or returned to the pharmacy (in accordance with pharmacy policy and state and federal law) within 30 days; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff performed acceptable infection control practices to prevent contamination when staff failed to place oxygen tubing in a plastic bag while not in use and placed contaminated nasal cannula prongs in one resident's (Resident #51) nares of 21 sampled residents. The facility also failed to ensure staff did not handle medication with their bare hands for one resident (Resident #30). Staff failed to follow appropriate handwashing after peri-care and the removal of a soiled dressing, touching the resident and supplies with soiled gloves for one resident (Resident #29). The facility's census was 67. Review of the facility's Hand Hygiene policy, dated 2019, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standard of practice by failure to follow the facility's policy for Hypoglycemic (low blood sugar) Protocol for one resident (Resident #65), who presented with a low blood sugar, during a closed record review in a review of 21 sampled residents. The facility census was 67. Review of the facility policy Hypoglycemic Protocol, dated 1/27/09 and reviewed/revised 2/8/10, showed the following: -Policy: The facility provides the necessary care and services to ensure that each resident attains or maintains the highest practicable physical, mental and psychosocial well-being in accordance with the resident's comprehensive assessment and plan of care; -Procedure: Initial Evaluation: If blood sugar is found to be less than 60, assess resident's cognitive function and level of consciousness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately recognize, evaluate and manage pain for one resident (Resident #30), in a review of 21 sampled residents. The facility census was 67. During interview on 1/30/23 at 2:30 P.M., the Director of Nurses said the facility did not have a policy for pain. A comprehensive pain assessment was completed at admission, weekly for four weeks, quarterly and with a significant change. Review of Resident #30's face sheet, undated, showed his/her diagnoses included Parkinson's disease (a progressive and debilitating neurological disorder that affects movement and often includes tremors), restless leg syndrome (a condition characterized by a nearly irresistible urge to move the legs, typically in the evenings and/or while sitting or lying down) and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five nurse aides (NA N, NA O, NA P, NA Q and NA R) completed a nurse aide training program within four months of their employment in the facility. The facility census was 67. 1. During email correspondence on 2/1/23 at 10:57 A.M., the Director of Nurses (DON) said the facility did not have a policy that addressed nurse aide training. 2. Record review of Nurse Aide (NA) N's employee file showed the following: -Date of Hire: 11/24/21; -NA A classroom and on the job training hours completed on 8/26/22; -NA A approved for Certified Nurse Assistant (CNA) final examination and not completed; -The facility failed to ensure the completion of the program within four months of the hire date. 3. Record review of NA O's employee file showed the following: -Date of Hire: 2/3/22; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal (lung inflammation caused by bacterial or viral infection) vaccines to two residents (Residents #6 and #59), in a review of 21 sampled residents. The facility census was 67. Review of the facility policy, Pneumococcal Vaccine Program, dated 2020, showed the following: -It is the policy of this facility that residents will be offered immunization(s) against pneumococcal disease in accordance with Advisory Committee on Immunization Practices (ACIP) recommendations; -There are two pneumococcal vaccines indicated for use among adults 65 years and older: 13 valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23); -A physician order for both PPSV23 and PCV13 is required; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the census and total hours worked by nursing staff (registered nurse (RN), certified nurse assistant (CNA), certified medication technician (CMT), and licensed practical nurse (LPN)) for each shift. The facility census was 67. Review of the facility's undated policy, New Staff Posting Form Instructions, showed the following: -Staff posting form will be initiated by the day shift house supervisor (HS). It needs to be filled out for the 7-3 shift by 9:00 A.M.; -The 3-11 and 11-7 HS will fill out the information for their shift by first break; -All HSs will need to update staffing and census changes that occurs during their shifts. Be sure when you leave that the activity/information that occurred during your shift is accurate. 1. Observation on 1/24/23 at 2:37 P.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff wore proper hair restraints during meal preparation and service. The facility census was 64. Observations on 6/04/19 between 9:12 A.M. through 12:42 P.M. during the noon meal preparation showed the following: -At 9:39 A.M. [NAME] W had a beard and did not wear a beard restraint. He/She dished up fruit for lunch in the main kitchen; -At 10:04 A.M. [NAME] X had a mustache that was not covered with a hair restraint. He/She prepared food in the main kitchen for the noon meal. The dietary manager's mustache was not covered. He walked around the main kitchen while the noon meal was being prepared. Two electrical workers were working in the kitchen area with no hairnets. One electrical worker had a beard that was not covered; -At 10:51 A.M., the electrical worker, who had a beard, was in the kitchen with no beard restraint. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff washed their hands after each direct resident contact and when indicated by professional standards of practice during personal care for two residents (Residents #8 and #116), in a review of 16 sampled residents; failed to wash hands and apply gloves when administering eye drops for one resident (Resident #19); and failed to develop a facility policy to address Legionella. The facility census was 64. 1. Review of the undated facility policy, Wash Hands, showed the following: -Apply a generous amount of soap to hands. Do not use bar soap; -Scrub hands for at least 15 seconds. Wash palms and back of hands with at least ten circular motions. Wash fingers and between fingers with at least ten circular motions. Wash wrists with at least ten circular motions, and wash around and under fingernails; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe environment by not ensuring water from the showers in residents' rooms on the 300 hall was contained to the showers and did not present as a hazard to other areas in the bathroom. The facility census was 64. Observations on 6/4/19 between 8:00 A.M. and 6:00 P.M. showed the following: -Occupied resident room [ROOM NUMBER] had a shower that ran water out onto the floor in the bathroom; -Occupied resident room [ROOM NUMBER] had a shower that ran water out onto the floor in the bathroom; -Occupied resident room [ROOM NUMBER] had a shower that ran water out onto the floor in the bathroom; -Occupied resident room [ROOM NUMBER] had a shower that ran water out onto the floor in the bathroom; -Occupied resident room [ROOM NUMBER] had a shower that ran water out onto the floor in the bathroom; [...]

Inspectors wroteBased on interview and record review, the facility failed to update the plan of care with interventions identified following falls for four residents (Residents #8, #13, #25, and #37), in a review of 16 sampled residents. The facility census was 64. 1. Review of the facility's policy, Resident Care Plan Procedure, undated, showed the following: -The care plan must be reviewed and revised (updated) as necessary, but at least every three months. Problems, goals, and approaches must be reviewed and revised when appropriate and necessary; three months is the maximum time limit for care. Three months may be too long and not reasonable for certain short-term goals. Care plans may need to be revised when new orders are obtained; -NOTE: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided three residents (Residents #8, #14, and #116), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal and oral hygiene, in a review of 16 sampled residents. The facility census was 64. 1. Review of the Nurse Assistant in a Long-Term Care Facility manual, 2001 revised edition, showed the procedures staff was to follow when providing perineal care for a male (steps 7 through 13) included the following: -Cover the resident; -Expose the perineal areas, wash the penis from the tip downward, rinse, and dry (specific instructions for uncircumcised); -Wash and rinse the scrotum; -Wash and rinse other skin areas between the legs; -Wash and rinse the anal area; -Pat the area dry. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities based on the activity assessment with specific goals and approaches, taking into account the resident's needs, strengths, and preference as part of a comprehensive care plan for two residents (Residents #14 and #46), who resided in the special care unit, in a review of 16 sampled residents. The facility census showed eight residents resided in the special care unit. The facility census was 46. 1. Review of the facility's undated policy, Resident Activities, showed the following: -Provision is made for rehabilitative and restorative activities under the direction and supervision of the activities director; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper safety techniques were utilized during transfers for two residents (Residents #6 and #14), in a review of 16 sampled residents, and during transport in a wheelchair for one additional resident (Resident #216). The facility failed to secure a wardrobe closet after it fell on one resident (Resident #11). The facility failed to ensure exit doors equipped with a Wanderguard system (a system for locking and/or alarming doors when residents with a Wanderguard device approach the door) functioned properly in the presence of the Wanderguard device. The facility census was 64. 1. Review of the facility's undated policy, Gait Belt Policy, showed the following: -Purpose: To assure the patient and caregiver safety during transfers and ambulation; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at a safe and appetizing temperature. The facility census was 64. Observation on 6/4/19 showed the following: -At 12:33 P.M., staff served the first resident in the [NAME] dining room (satellite kitchen 1). Staff continued to serve residents from the steam table. The main entree for the meal was chicken; -At 12:59 P.M., the test tray was received immediately after the last resident was served. The temperature of the non-barbequed chicken (chicken served to residents on low salt and low concentrated sweet diets) was 111 degrees Fahrenheit, and ground barbequed chicken was 109 degrees Fahrenheit. The chicken was cool when taste tested. Observation on 6/5/19 showed the following: -At 12:02 P.M., staff served the first resident in the Parc Place dining room (satellite kitchen 2). [...]

Inspectors wroteBased on interview and record review, the facility failed ensure the policy for pneumococcal vaccinations was consistent with the current Centers for Disease Control (CDC) guidelines; failed to offer and vaccinate eligible residents with the pneumococcal vaccines as indicated by the current guidelines, unless the resident had previously received the vaccines, refused, or had a medical contraindication present; and failed to ensure the medical record included evidence education was provided to the resident or the resident's representative on the benefits and potential side effects of the pneumococcal vaccination for two residents (Residents #116 and #13), in a review of 16 sampled residents, and two additional residents (Residents #20 and #62). The facility census was 64. 1. Review of the facility policy Pneumococcal Vaccine Policy, dated 2017, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #116) who had enteral feedings through a gastrostomy tube (surgically placed tube into the stomach for enteral nutritional feedings), in a review of 16 sampled residents. The facility reported three residents with feeding tubes. The facility census was 64. Review of Resident #116's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/5/19, showed the following: -Severely impaired cognition; -Feeding tube; -Diagnoses included dementia and stroke. Review of the resident's care plan, revised 5/24/19, showed the following: -Diagnosis of dysphagia (difficulty in swallowing); -The resident is to receive nothing by mouth (NPO) and receives feeding through a gastrostomy tube; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician when staff identified a newly developed Stage II pressure ulcer (partial thickness skin loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough), and failed to obtain a physician order for treatment for one resident (Resident #216), in a review of 16 sampled residents. The facility reported four residents with pressure ulcers. The facility census was 64. 1. Review of the facility's undated policy, Pressure Ulcers (Decubitus Ulcers), showed the following: -Promote healing of pressure ulcers; -See physician orders for treatment to be done for each pressure ulcer. Follow orders; -Pressure ulcers are to be measured at least weekly. Document each time treatment is done. Give detailed documentation at least weekly. [...]