Twin Towers

Based 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. On 02/05/26, the resident weighed 98.2 lb. On 02/18/26, the resident weighed 96 lb. On 02/22/26, the resident weighed 94.3 lb. On 02/24/26, the resident weighed 93 lb. Review of the comprehensive Minimum Data Set (MDS)…

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 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.). Review of the nutrition progress note for Resident #10 dated 11/21/25 and authored by Registered Dietician (RD) #605, revealed Resident #10's…

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 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. Findings included: 1. During an observation on 08/26/24 at 9:09 A.M., Preparation (Prep) [NAME] #6 was observed preparing food with a full beard and no beard cover. During an interview on 08/26/24 at 9:35 A.M., Prep [NAME] #6 stated he was preparing the ham and putting up buns when the surveyor entered the kitchen. He stated he did not know if he should have been wearing a beard cover. During an interview on 08/26/24 at 9:40 A.M., the Dietary Manager (DM) stated Prep [NAME] #6 should have had a beard cover on while preparing food. During an interview on 08/29/24 at 10:18 A.M., the Administrator stated beard covers should be worn when preparing food. Review of a facility policy titled, Orientation and Education, revised 01/2024, revealed in the section…

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 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. Finding included: During an observation on 08/26/24 at 1:48 P.M., State Tested Nurse Aide (STNA) #8 was observed coming out of a COVID-19 positive resident's room with a bag of soiled items. STNA #8 had on a surgical mask and gloves. During a concurrent interview STNA #8 stated, when entering the room with a COVID-19 positive resident, she would put an N95 (respirator) mask on top of a surgical mask, gown, face shield, and gloves. STNA #8 stated there was a bin inside the room to discard all the personal protective equipment (PPE). STNA #8 stated she would discard everything and when she would exit the room, she would just have on a surgical mask and would put new gloves on when she came out. STNA #8 stated she had not been fit tested for…

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 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. Findings included: Review of a profile face sheet revealed the facility admitted Resident #49 on 10/26/22. According to the profile face sheet, the resident had a medical history that included diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/04/24, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated the resident had an indwelling urinary catheter. Review of Resident #49's physician orders contained an order dated 04/23/24 to change F/C (Foley catheter) #18 French size (Fr), a universal gauge system used to measure…

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, 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. Findings included: Review of a profile face sheet revealed the facility admitted Resident #49 on 10/26/22. According to the profile face sheet, the resident had a medical history that included diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/04/24, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated the resident had an indwelling urinary catheter. Review of Resident #49's physician orders contained an order dated 04/23/24 to change F/C (Foley catheter) #18 French size (Fr), a universal gauge system used to…

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 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. Findings included: Review of a profile face sheet revealed the facility admitted Resident #49 on 10/26/22. According to the profile face sheet, the resident had a medical history that included diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/04/24, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated the resident had an indwelling urinary catheter. Review of Resident #49's physician orders contained an order dated 04/23/24 to change F/C (Foley catheter) #18 French size (Fr), a universal gauge system…

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 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. Findings included: 1. Review of a profile face sheet revealed the facility admitted Resident #58 on 09/20/23. According to the profile face sheet, the resident had a medical history that included diagnoses of Alzheimer's disease and dementia with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/24/24, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS assessment revealed the resident received antipsychotic and antidepressant medications during the assessment period. Review of Resident #58's care plan included a category for psychotropic drug use, initiated 10/03/23, that indicated the resident had the potential for drug related…

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, 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. Findings included: 1. Review of a profile face sheet revealed the facility admitted Resident #29 on 09/18/23. According to the profile face sheet, the resident had a medical history that included diagnoses of chronic kidney disease stage three and urinary tract infections. Review of Resident #29's physician's orders included an order dated 08/07/24 for the supplement cranberry concentrate 500 milligram (mg) capsule by mouth daily for recurrent urinary tract infections. During an observation of medication administration on 08/28/24 at 8:36 A.M., Registered Nurse (RN) #14 administered Azo-Cranberry for urinary tract health. During an observation and interview on 08/28/2024 at 3:32 P.M., RN #14…

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, 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. In the walk-in produce refrigerator there were two large bags of unopened vegetables with no label and date. In the dry storage area there was a bag of identified macaroni undated and unlabeled. Interview on…

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 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]. Diagnoses included dysphagia, Parkinson's disease, hypothyroidism, and atrial fibrillation. Review of the MDS comprehensive assessment dated [DATE] revealed Resident #35 had intact cognition and received pureed…

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.