Twin Ports Health Services

In the surveyor’s words

From the most serious findings on record at Twin Ports Health Services, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 25, 2024

  Based on observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. This had the potential to affect all 78 of 78 residents that eat orally. Food (milk and lettuce) placed in the walk-in cooler had been opened but was not labeled with an opened date, resulting in the potential for foodborne illnesses to spread. Findings include: The facility's policy entitled Food Storage dated 8/16/2022, states in part, .Refrigerated food storage: . f. All foods should be covered. Labeled and dated. […]

• No harm, potential for more than minimal, patternF880Jan 22, 2026

  Based on observation, interview and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 10 of 79 residents (R) observed for infection control practices.Certified Nursing Assistant (CNA) I did not perform proper glove changes and hand hygiene during cares.Staff did not use appropriate infection control practices. No hand hygiene between residents while passing meal trays and the meal trays were placed on dirty Personal Protective Equipment (PPE) container. CNA D served R78 a meal tray and placed it on a contaminated surface. […]

• No harm, potential for more than minimal, isolatedF684Jan 22, 2026

  Based on observations, interviews and record reviews, the facility did not provide wound management or diabetic management by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 3 residents (R32) reviewed.-Staff did not provide wound care dressing as ordered by physician for R32. -R32's air mattress settings were not appropriate per R32's weight based on offloading measures to minimize skin breakdown. -Staff did not administer short acting insulin to R32 when Blood Glucose (BG) was high.Findings include:Facility policy titled Change in Condition of the Resident, last revised 09/20/22, stated in part, .When a resident presents with a possible change of condition or noted changes in mental or physical functioning: 1. […]

• No harm, potential for more than minimal, isolatedF686Jan 22, 2026

  Based on interview and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 3 resident (R) reviewed. (R44)R44 was admitted to the facility with stage 3 PIs to left trochanter (hip) and left buttock and stage 2 PIs to the right hip and right buttocks. Facility staff did not complete a comprehensive PI assessment to include measurements and description of R44's PIs on admission. Facility staff on the following assessment documented all the PIs only at a stage 2. […]

• No harm, potential for more than minimal, isolatedF689Jul 18, 2025

  Based on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R)(R1) reviewed.The facility does not have a policy or procedure in place to assess risk for residents storing and using a personal vehicle on facility premises.R1 eloped from facility using personal vehicle parked on facility premises.This is evidenced by:State Operations Manual, Appendix PP, states in part: The facility must ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision.to each resident to prevent avoidable accidents. […]