Twin Willows Nursing Center

Inspectors wroteBased on interview and record review the facility failed to provide the consulting services of a Registered Dietician. This failure has the potential to affect all 22 residents that reside at the facility.

Inspectors wroteBased on interview, observation, and record review the facility failed to maintain a safe, clean, sanitary environment in the common foyer area of the facility. This failure has the potential to affect all 22 residents residing at the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to provide an accessible call light for the shower room on the north hall for 10 (R5, R7, R8, R9, R10, R12, R15, R18, R20, and R22) of 10 residents reviewed for assessable call lights in a sample of 22.

Inspectors wroteBased on interview, observation, and record review the facility failed to serve food in the appropriate texture for 4 (R7, R8, R15, and R22) of 10 residents reviewed for dining in a sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain adequate infection control practices including hand hygiene, identification of appropriate isolation, and proper handling of soiled linens for 6 of 6 residents (R2, R5, R7, R9, R18, and R20) reviewed to infection control in the sample of 22.

Inspectors wroteBased on interview, observation and record review the facility failed to provide eating assistance with respect and dignity for 2 (R12, R18) of 3 residents reviewed for dignity in a sample of 22.

Inspectors wroteBased on interview and record review the facility failed to ensure Uniform Practitioner Orders For Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout resident health record for 1 of 2 residents (R19) reviewed for advanced directives in a sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, sanitary environment for one (R2) of ten residents reviewed for a safe, clean, sanitary environment in a sample of 22.

Inspectors wroteBased on interview, observation and record review the facility failed to accurately assess a resident eating abilities for 1 of 1 resident (R2) reviewed for accuracy of assessments in a sample of 22.

Inspectors wroteBased on interview, observation and record review the facility failed to provide assistance with eating assistance in a timely manner and failed to ensure that residents who require assistance with showering received a shower for 2 of 4 residents (R2, R7) reviewed for Activities of Daily Living in a sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise residents who are at risk of choking during meals for 1 of 1 resident (R23) reviewed for supervision in the sample of 22.

Inspectors wroteBased on interview, observation and record review the facility failed to assess, monitor and document meal intakes on resident who is considered underweight for weight gain/loss for 1 of 5 residents (R9) reviewed for weight loss in a sample of 22.

Inspectors wroteBased on interview, observation and record review the facility failed prevent cross contamination of drinking glasses during meal service. This failure has the potential to affect all 24 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, sanitary, and clean home-like environment for the residents. This has the potential to affect all 24 residents residing at the facility. Findings including: On 01/13/24 at 12:53 PM, the shower room on the 200 hall had an accumulation of dirt and mildew along the edges between the floor and the wall in the caulk of all three walls of the shower stall. In this same room there is was accumulation of dirt on the floor in between the 1 inch by 1 inch tiles. There is an accumulation of dirt and debris along the edge of the bottom of the toilet where the toilet meets the floor. There was an approximate 2 millimeter black ring inside the toilet bowl. There was a large linen barrel and trash can blocking access to the hand washing sink. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were within reach for 6 of 7 residents (R1, R5, R11, R19, R21, R24) reviewed for call lights on the sample list of 23.

Inspectors wroteBased on interview, observation and record review the facility failed to promote dignity for 1 of 4 (R17) reviewed for dignity in a sample of 23.

Inspectors wroteBased on interview, and record review the facility failed investigate a bruise of unknown origin for 1 (R13) of 1 resident reviewed for bruises of unknown origin in a sample of 23.

Inspectors wroteBased on interview, observation and record review the facility failed to provide necessary services that are consistent with professional standards to prevent the worsening of pressure ulcers for 1 of 2 residents (R4) reviewed for pressure ulcers in a sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to implement active, cognition appropriate and progressive interventions to prevent falls for three (R5, R19, R21) of six residents reviewed for falls in a sample of 23.

Inspectors wroteBased on interview, observation and record review the facility failed to follow the facility policy for weight loss for one (R24) resident of 3 residents in a sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with dementia received the necessary person-centered care and services to address wandering behavior for 1 of 1 resident (R14) reviewed for Dementia in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper infection control technique during incontinent care for 1 of 2 (R4) residents observed for incontinent care in a sample of 23.

Inspectors wroteBased on interview, observation, and record review the facility failed to follow standards of practice for antibiotic use for one (R3) of one resident reviewed for antibiotic use in a sample of 23.

Inspectors wroteBased on interview, record review and observation the facility failed to post daily nurse staffing data for licensed and unlicensed staff responsible for resident care. This failure has the potential to affect all 24 residents who reside at this facility.

Inspectors wroteBased on observation interview and record review the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect all 29 residents currently residing at the facility. Findings Include: The facility Wing Group Assignments provided to this surveyor on 7/6/24 documents 29 residents currently reside at the facility. On 7/6/24 at 9:26 AM, V2 (Director of Nurses) stated the facility freezer went down and they moved all of the food off premises to a dedicated freezer in a secure place at V2's house. V2 stated they maintain the temperature of the freezer. V2 was unable to provide this surveyor with reproducible evidence the temperature of the freezer/food was maintained per current standards of practice. On 7/6/24 at 10:06 AM, V4 (Cook) stated they don't have a working freezer at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments were successfully transmitted within 14 days of completion for 1 (R9) of 12 residents reviewed for assessments in the sample of 22. Findings Include: R9's admission Record documented an initial admission date to the facility as 12/20/2018. Diagnoses included, but were not limited to: unspecified dementia, dysphagia, type 2 diabetes mellitus, seizures, macular degeneration, etc. Review of R5's Minimum Data Set, dated (MDS) 7/29/23, documented the type of assessment as being a reporting entry for death in facility. This same assessment documented the discharge date for R9 in section A2000 as 07/29/2023. On 01/03/24 at 02:40 PM, V5 (Medical Records) stated the death in facility MDS was completed on for R9 on 7/29/23. [...]

Inspectors wroteBased on interview and record review the facility failed to offer/provide showers for 2 of 12 (R136 and R137) residents reviewed for showers in a sample of 22. The Findings Include: 1. R137's admission record documents an admission date of 12/28/23 with diagnoses including heart failure and unspecified osteoarthritis. R137 does not yet have a completed Minimum Data Set, but R137 was alert to person, place, and time during the interview on 1/3/24 at 10:00 AM. R137's baseline care plan dated 12/28/23 documents she is dependent for showers. On 1/3/24 at 10:00 AM, R137 stated she has not had a shower since admission, and they changed her out of her pajamas at 4AM and put her clothes on from the previous day. R137 stated at this time she would like to have clean clothes on daily and to not get too close because she likely smells. [...]