Twin Ports Health Services

Inspectors wroteBased on observation, interview and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 10 of 79 residents (R) observed for infection control practices. Certified Nursing Assistant (CNA) I did not perform proper glove changes and hand hygiene during cares. Staff did not use appropriate infection control practices. No hand hygiene between residents while passing meal trays and the meal trays were placed on dirty Personal Protective Equipment (PPE) container. CNA D served R78 a meal tray and placed it on a contaminated surface. Example 1 Facility policy titled, Hand Hygiene revised 11/02/2022 stated in part: 1. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not provide wound management or diabetic management by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 3 residents (R32) reviewed.-Staff did not provide wound care dressing as ordered by physician for R32. -R32's air mattress settings were not appropriate per R32's weight based on offloading measures to minimize skin breakdown. -Staff did not administer short acting insulin to R32 when Blood Glucose (BG) was high.

Inspectors wroteBased on interview and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 3 resident (R) reviewed. (R44)R44 was admitted to the facility with stage 3 PIs to left trochanter (hip) and left buttock and stage 2 PIs to the right hip and right buttocks. Facility staff did not complete a comprehensive PI assessment to include measurements and description of R44's PIs on admission. Facility staff on the following assessment documented all the PIs only at a stage 2. [...]

Inspectors wroteBased on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R)(R1) reviewed. The facility does not have a policy or procedure in place to assess risk for residents storing and using a personal vehicle on facility premises. R1 eloped from facility using personal vehicle parked on facility premises. This is evidenced by:State Operations Manual, Appendix PP, states in part: The facility must ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision.to each resident to prevent avoidable accidents. This includes: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. This had the potential to affect all 78 of 78 residents that eat orally. Food (milk and lettuce) placed in the walk-in cooler had been opened but was not labeled with an opened date, resulting in the potential for foodborne illnesses to spread.

Inspectors wroteBased on interview and record review, the facility did not send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman for 3 of 7 residents reviewed who were discharged with return anticipated. (R7, R25 and R66). This is evidenced by: The facility policy, entitled Transfer and Discharge last reviewed and revised on 07/15/22, states under Section 7(k). Emergency Transfers/Discharges, Social Services Director (SSD), or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. Example 1 R7 was admitted to the facility on [DATE] and has diagnoses that include congested heart failure, diabetes mellitus, chronic kidney disease, and post-traumatic stress disorder. R7's Minimum Data Set (MDS) assessment, dated 05/03/24, indicated that R7 was transferred to an acute care hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that written bed hold notice and reason for transfer required for facility-initiated transfers was provided to the residents or resident representatives at time of hospital transfer or within 24 hours of transfer for 2 of 2 residents (R7 and R66) reviewed for hospitalization. This is evidenced by: The facility policy, entitled (I) Transfer and Discharge last reviewed and revised on 07/15/22, states under Section 7 (i), Provide a notice of the resident's bed hold policy to the resident and representative at the time of the transfer, as possible, but no later than 24 hours of the transfer. Example 1 R7 was admitted to the facility on [DATE] and has diagnoses that include congested heart failure, diabetes mellitus, chronic kidney disease, and post-traumatic stress disorder. [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 1 of 18 sampled residents (R) R6, to meet a resident's medical, nursing, and psychosocial needs that are identified. R6 did not have a comprehensive person-centered care plan for trauma informed care identifying triggers related to post traumatic stress disorder (PTSD).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident with a urinary catheter received appropriate treatment to prevent urinary tract infections for 1 of 2 residents (R) with urinary catheters. (R33) Certified Nursing Assistant (CNA) did not follow proper procedure for urinary catheter care to prevent risk of infection.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when staff did not perform hand hygiene after removing soiled gloves during care observations. This affected 2 of 4 residents (R) observed for cares. (R33 and R328) Certified Nursing Assistant (CNA) did not perform hand hygiene when changing gloves during catheter cares. CNA did not perform hand hygiene when changing gloves after emptying urinary drainage bag. Registered Nurse (RN) did not perform hand hygiene after removing gloves following wound care.