Twin Towers

Inspectors wroteBased on medical record review, observation, staff interview, review of facility policy, and review of online guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to identify pressure ulcers (injuries to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony areas like the hips, heels, or tailbone) until they had reached an advanced stage. [...]

Inspectors wroteBased on medical record review, family interview, staff interview, and policy review, the facility failed to ensure resident responsible parties were notified of changes in condition. This affected two Residents (#08 and #12) of the five residents reviewed. The facility census was 61. Review of the medical record of Resident #08 revealed an admission date of 12/08/25. Diagnoses included end-stage renal disease (ESRD), dependence on renal dialysis, chronic obstructive pulmonary disease (COPD), and hypothyroidism. Review of the medical record revealed on 12/09/25, Resident #08 weighed 118.6 pounds (lb.). On 12/13/25, the resident weighed 112 lb. On 12/23/25, the resident weighed 113.6 lb. On 12/31/25, the resident weighed 110.8 lb. On 01/10/26, the resident weighed 109.6 lb. On 01/21/26, the resident weighed 105.4 lb. On 01/01/26, the resident weighed 100.4 lb. [...]

Inspectors wroteBased on record review, staff interviews and policy review, the facility failed to adequately monitor residents' weights to ensure accuracy of documented weight loss/gain. This affected two Residents (#10 and #12) out of three residents reviewed for nutrition. The facility census was 61. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Parkinsonism, cognitive communication deficit, and bipolar disorder. Review of the physician order dated 10/04/24, revealed Resident #10 was ordered to receive a regular diet, regular consistency. Review of the weights for Resident #10 revealed the resident had documented weights on 10/08/25 of 195 pounds (lbs.) and on 11/21/25 of 172.8 lbs. This represented an 11.38 percent (%) weight loss in forty-three days. The resident's next documented weight was on 12/19/25 (204.4 lbs.). [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure staff properly stored frozen foods and staff with beards wore beard guards during preparation of food to prevent contamination. The failure had the potential to affect 72 residents who received meals from the kitchen. The census was 72.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure that staff were fit tested for a respirator required for respiratory protection when working with Coronavirus Disease 2019 (COVID-19) positive residents. This had the potential to affect all 72 residents that resided in the facility. The census was 72.

Inspectors wroteBased on staff interview, medical record review, and facility policy review, the facility failed to notify the physician related to bleeding during indwelling urinary catheter changes for one (Resident #49) of three sampled residents reviewed for urinary catheters. The census was 72.

Inspectors wroteBased on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure staff followed physician orders for indwelling urinary catheter care for one (Resident #49) of three sampled residents reviewed for urinary catheters. The census was 72.

Inspectors wroteBased on staff interview and medical record review, the facility failed to ensure nursing staff possessed and demonstrated competencies and skill set necessary to provide indwelling urinary catheter care for one (Resident #49) of the sampled residents reviewed for urinary catheters. The census was 72.

Inspectors wroteBased on staff interview, medical record review, and facility policy review, the facility failed to ensure pharmacy recommendations were implemented for two (Resident #58 and Resident #72) of five sampled residents reviewed for unnecessary medications. The census was 72.

Inspectors wroteBased on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure the medication error rate was less than five percent (%). There were five errors out of 31 opportunities, which resulted in a medication error rate of 16.13% for two (Resident #29 and Resident #49) of three residents observed for medication administration. The census was 72.

Inspectors wroteBased on observation, interview policy review, the facility failed to label and date foods, accurately test for dishwasher sanitation and use hand gloves in a sanitary manner during food service. This had the potential to affect all the resident's receiving food from the kitchen. The total facility census was 76. Findings Include: 1. During the kitchen tour observation on 10/31/22 at 8:30 A.M. revealed the following sanitation violations in the main kitchen: The ice machine scoop was laying horizontally on a counter and not draining vertically. In the walk in refrigerator there were undated, uncovered yogurt fruit plates, a serving container of gravy, and tub of macaroni and cheese. There were 12 undated and unlabeled pies and four serving containers of egg salad. There were two opened undated bags of bread. In the walk-in freezer there was food and paper debris on the floor. [...]

Inspectors wroteBased on medical record review, observation, staff interview, review of the recipes, review of the menu spreadsheet, and policy review, the facility failed to provide puree foods as planned by a Registered Dietitian. This affected two residents (#27 and #35) out of three residents reviewed for puree food diets. The facility census was 76. Findings Include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included bone necrosis of the mouth gums, dysphagia and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and received puree thin liquid diet. 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. [...]