Twin Towers

In the surveyor’s words

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

• Actual harm, isolatedF686Feb 26, 2026

  Based on medical record review, observation, staff interview, review of facility policy, and review of online guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to identify pressure ulcers (injuries to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony areas like the hips, heels, or tailbone) until they had reached an advanced stage. This resulted in Actual Harm for Resident #66 on 02/16/26, when the resident was admitted to the facility without pressure ulcers, was assessed to be at high risk for development of pressure ulcers and developed an avoidable unstageable pressure ulcer (a full-thickness wound where damage depth is hidden by slough [a soft, moist,… […]

• No harm, potential for more than minimal, widespreadF812Aug 30, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF880Aug 30, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF812Nov 3, 2022

  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. […]

• No harm, potential for more than minimal, patternF880Feb 19, 2021

  Based on observations, policy review, and staff interviews the facility failed to maintain transmission-based precautions on two of five units observed for transmission-based precautions. 1.) The facility staff failed to dispose of soiled disposable isolation gowns appropriately and failed to perform hand hygiene after removal of personal protective equipment upon leaving the rooms of five of five residents (Resident) (R) 4, R7, R8, R9, and R11) who were on transmission-based precautions on the rehab (quarantine) unit. This failed practice had the potential to affect all 15 residents who resided on the rehab unit. 2.) The facility failed to ensure proper handling of soiled isolation linens and a trash bag on one of five units observed for transmission-based precautions. […]