Twin City Trails of Journey LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews, record review, and review of the facility policy titled ABUSE, NEGELECT, [sic] AND EXPLOITATION, the facility failed to protect the resident's right to be free from physical abuse for one of 16 sampled residents (R) (R3). Specifically, R13 pushed R3, causing a fall. This deficient practice had the potential to place R3 at increased risk of injury related to being pushed. Findings include:Review of the facility's policy titled ABUSE, NEGELCT, [sic] AND EXPLOITATION, reviewed 03/05/2024, documented Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident.that prohibit and prevent abuse. In addition, documented Definitions: 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. and .'Physical Abuse' includes, but is not limited to hitting,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled ABUSE, NEGELECT, [sic] AND EXPLOITATION, the facility failed to report a resident-to-resident physical altercation to the State Survey Agency (SSA) within the required timeframe for two of 16 sampled residents (R) (R3 and R13). Specifically, R3 fell as a result of being pushed by R13. This deficient practice had the potential to increase the risk of other potential abuse not being reported. Findings include:Review of the facility's policy titled ABUSE, NEGELCT, [sic] AND EXPLOITATION, reviewed 03/05/2024, documented Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident.that prohibit and prevent abuse. In addition, documented Definitions: 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled ABUSE, NEGELECT, [sic] AND EXPLOITATION, the facility failed to thoroughly investigate a physical altercation between two of 16 sampled residents (R) (R3 and R13). Specifically, R13 pushed R3, causing a fall. This deficient practice had the potential to increase the risk for abuse to continue. Findings include:Review of the facility's policy titled ABUSE, NEGELCT, [sic] AND EXPLOITATION, reviewed 03/05/2024, documented Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident.that prohibit and prevent abuse. In addition, documented Definitions: 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. and .'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility policies titled Food Preparation and Service F804 F812 and Refrigerators and Freezers F812, the facility failed to store foods in accordance with professional standards for food service safety. Additionally, the facility staff failed to record the daily temperatures of the refrigerator and freezer for two of two observed for temperature logs. The deficient practices had the potential to place 75 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: A review of the facility policy titled Food Preparation and Service F804 F812, last revised 10/23, revealed: Residents are provided with meals that are prepared by methods that conserve value, flavor, and appearance. Residents are provided with food and drink that is palatable, attractive, and at a safe and appetizing temperature. On 6/18/2024, at 9:30 am, during the initial tour of the kitchen with the Dietary Manager (DM), one pack of moldy sub sandwich rolls [six-count] was observed stored with ready-to-eat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility policy titled Sanitation F812, the facility failed to ensure doors in the main kitchen remained in good repair to prevent pests from invading the main kitchen and one of two dining areas. This failure had the potential for pests to transfer harmful microorganisms to food leading to foodborne illness for the 75 residents receiving food from the kitchen. Findings include: A review of the facility's policy titled Sanitation F812, effective 10/23, revealed: 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Observation of the main kitchen on 6/18/2024 at 10:00 am, 6/19/2024 at 11:00 am, and 6/19/2024 at 12:15 pm revealed a substantial number of live flies in the kitchen area. This observation was confirmed in the presence of the Dietary Manager (DM), who was interviewed. On 6/18/2024 at 10:00 am, observation found the back door in the main kitchen was slightly open, with an opening at the top of the door. The DM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility policy titled Safe, Clean, Comfortable, Homelike Environment F584, the facility failed to ensure that maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment were provided. Specifically, 11 of 38 resident rooms were found in disrepair. These deficient practices had the potential to place residents at risk for the use of unsanitary and unsafe equipment and a potential for diminished quality of life. Findings include: A review of a facility policy titled Safe, Clean, Comfortable, Homelike Environment F584, dated effective 9/2023, revealed: Policy Statement: F 584 Residents have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports [sic] for daily living safely. Policy Interpretation and Implementation: 1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, review of facility-posted signage and temperature logs, and a review of the facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, the facility failed to store vaccines under proper temperature controls with twice daily monitoring and failed to remove from use medications, needles, and laboratory supplies that were kept past their expiration dates in one of one medication storage room and one of two medication carts reviewed. This deficient practice created the potential for residents to receive vaccinations with altered effectiveness and the potential for the use of expired medical and laboratory supplies. Findings include: The facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, revised [DATE], stated: APPLICABILITY: This Policy 5.3 sets forth the procedures related to the storage and expiration dates of medications, biologicals, syringes and needles. PROCEDURE: . 4. Facility should ensure that medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility policy titled Answering the Call Light, the facility staff failed to ensure resident call lights were within reach for three of 18 sampled residents (R) (R5, R46, R70). This failure placed R5, R46, and R70 at risk of accident, injury, and/or unmet needs related to an inability to call for staff assistance. Findings include: A review of the facility policy titled Answering the Call Light, with a review date of 9/2023, revealed: General Guidelines 5. When a resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 1. A review of R5's quarterly Minimum Data Set (MDS), dated [DATE], revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 10 (indicating moderate cognitive impairment), and section GG (Functional Abilities and Goals) documented the resident required supervision with Activities of Daily Living (ADLs). During the initial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and review of the facility policy titled Handwashing/Hand Hygiene F 880, the facility failed to ensure staff administered medications via gastrostomy tube (G-Tube) (a tube surgically placed through the skin into the stomach to provide nutrition, hydration, and medication) to one resident (R) (R46) in a manner to prevent the development and transmission of infections. This deficient practice placed R46 at risk of contracting avoidable infections. Findings include: The facility policy titled Handwashing/Hand Hygiene F 880, effective date 9/2023, stated: Guidelines: . 2. Staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub [ABHR]. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents; b. Before donning sterile gloves;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of facility policy 'Food Service Staffing', the facility failed to ensure that the staff designated as director of food and nutrition services was a certified dietary or food service manager or had a similar food service management certification or degree. The deficient practice had the potential to affect 73 of 77 residents that received an oral diet. Findings include: Review of policy titled 'Food Service Staffing' last revised 10/2022 revealed '5. If the Dietician is not full time, then the community will employ another qualified nutritional professional to serve as the Dietary Manager. The person at a minimum must meet-one of the following qualifications: a. A certified dietary manager; b. A certified food service manager; c. Have similar certification in food service management and safety from a national certifying body; d. Has an associates or higher degree in food services management or in hospitality, if the course study includes food service or restaurant management from an accredited institution of higher learning.'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a sanitary environment free of standing water in the dishwasher room, watering leaking into a plastic bin in the refrigerator, standing water under the ice machine with brown colored substance pooled beneath the ice machine, and a vent in the dry storage room with a thick coat of black substance. The facility also failed to maintain the holding temperature of five foods on the steam table above 135 degrees, to prevent the potential for food-borne illnesses. This had potential to affect 73 of 77 residents receiving oral diets. Findings include: 1. During initial tour of kitchen on 10/13/22 at 10:17 a.m. revealed water running under the ice machine from a pipe. The floor under and surrounding the ice machine was wet. Beneath the ice machine had a black substance on the floor running into the floor drain. Refrigerator located in kitchen has water dripping from a vent inside of the refrigerator. The floor in the dishwasher room is unlevel and standing water is noted under a waterproof floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview, the facility failed to ensure that essential equipment in the kitchen was in working order, specifically the steam table, one of two refrigerators, and one ice machine. This had the potential to affect 73 of 77 residents receiving an oral diet. Findings include: During initial tour of kitchen on 10/11/22 at 10:17 a.m. with [NAME] 'AA' revealed water running under the ice machine from one of the pipes. Refrigerator located in kitchen had water dripping from a vent inside the refrigerator into a plastic pan. During walk through of kitchen on 10/11/22 at 11:03 a.m. with Administrator confirmed the findings. Stated her expectation is for the dietary staff to report any equipment or environmental issues promptly. During observation of steam table temperatures on 10/13/22 at 11:53 a.m. with [NAME] 'AA' noted the steam table was not functioning properly. [NAME] 'AA' stuck her hand into one of the water basin and stated the water was tepid to touch. During interview on 10/13/22 at 2:15 p.m. with [NAME] 'AA' she revealed the maintenance director was going…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review, the facility failed to ensure that staff followed recipes for preparing pureed meals to avoid compromising the nutritive value of food items served to residents on a pureed diet when compared with items served to residents on a regular diet for 13 residents receiving a pureed diet. Findings include: Review of the lunch menu for 10/13/22 revealed items which included ranch baked chicken. During the preparation of pureed food items on 10/13/22 at 11:12 a.m. [NAME] 'BB' was observed placing approximately six slices of bread into the food processor. [NAME] 'BB' then placed an unmeasured amount of chicken into the food processor with liquid from the bottom of the pan holding the chicken. She turned the food processor on. After approximately 30 seconds, the cook checked the consistency of the bread/chicken mixture and scraped the sides of the food processor. [NAME] 'BB' then placed an additional six slices of bread into the food processor with an unmeasured amount of chicken and liquid from the pan holding the chicken. She then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.