Twin Pines Adult Care Center

In the surveyor’s words

From the most serious findings on record at Twin Pines Adult Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 7, 2021

  Based on interview and record review, the facility failed to consistently implement and modify interventions as necessary, in accordance with current standards of practice to prevent falls for two residents (Residents #1 and #3) in a review of ten sampled residents, and failed to ensure safety interventions in use, including bed alarms, functioned appropriately. Resident #3's cause of death was determined to be complications from an unwitnessed fall from the bed. Resident #1 sustained a concussion as a result of his/her fall. The facility's census was 51. The administrator was notified on [DATE] at 10:52 A.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite. […]

• Actual harm, isolatedF686Apr 7, 2021

  Based on interview and record review, the facility failed to identify a Stage II pressure ulcer on admission for one resident (Resident #4) of ten sampled residents and failed to notify the resident's physician to obtain orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The ulcer further declined and was classified as a Stage III pressure ulcer. The facility census was 51. Record review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of… […]

• No harm, potential for more than minimal, widespreadF585Oct 11, 2024

  Based on interview, record review, and policy review, the facility failed to have a grievance procedure with an identified person to lead investigations, a system to inform residents of their right to file a grievance, and documentation to show the results of grievance investigations for six of six residents (Resident (R) 1, R21, R28, R38, R48, and R56) interviewed in the resident group interview. The failure had the potential to affect all residents who resided at the facility to be informed of their right to file a grievance and for the facility to resolve any grievance the residents may have. […]

• No harm, potential for more than minimal, widespreadF812Oct 11, 2024

  Based on observation, interview, and facility policy review, the facility failed to ensure food stored in the kitchen was labeled and dated with an open date to ensure opened food items were discarded in a timely manner. This had the potential to increase the spread of foodborne illnesses for 72 out of 72 residents that receive meals from the kitchen. Findings include: Review of the facility's policy titled, Food Storage (Dry, Refrigerated, and Frozen), 2016 Edition, revealed Guideline: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. All food items will be labeled. […]

• No harm, potential for more than minimal, widespreadF944Oct 11, 2024

  Based on record review and interview, the facility failed to ensure that five of five employee files reviewed had the required Quality Assurance and Performance Improvement (QAPI) training. This failure had the potential to have a negative impact on staff for their unawareness about how to bring concerns to QAPI and in return this could impact the 72 residents currently residing at the facility. Findings include: Review of Certified Nursing Assistant (CNA)1's personnel file indicated CNA1's Date of Hire (DOH) was 08/16/23 and there was no evidence of CNA1 receiving the required QAPI training. Review of CNA6's personnel file indicated CNA6's DOH was 08/10/23 and there was no evidence of CNA6 receiving the required QAPI training. […]