Twin Willows Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF801Apr 3, 2026

  Based on interview and record review the facility failed to provide the consulting services of a Registered Dietician. This failure has the potential to affect all 22 residents that reside at the facility.Findings include:On 04/01/26 at 2:54 PM, V19 (previous Registered Dietician) stated, she is not familiar with any of the residents at the facility. V19 stated, she has not physically been at the facility since October 2023.On 04/01/26 at 3:10 PM, V8 (Dietary Manager) stated they currently do not have a RD (Registered Dietician), they have not had one since the end of 2023. V8 stated she does not do BMIs (Body Mass Index), goal weights, the amount of calories needed, or estimated calories given for the residents. […]

• No harm, potential for more than minimal, widespreadF921Apr 3, 2026

  Based on interview, observation, and record review the facility failed to maintain a safe, clean, sanitary environment in the common foyer area of the facility. This failure has the potential to affect all 22 residents residing at the facility.Findings include:On 03/30/26 at 8:50 AM the ceiling vent in the entrance foyer had a large accumulation of a black substance covering approximately 90 % of the vent with a concentration around the edges and the center of the vent.On 03/31/26 at 8:45 AM the ceiling vent in the entrance foyer had a large accumulation of a black substance covering approximately 90 % of the vent with a concentration around the edges and the center of the vent.On 04/01/26 at 8:30 AM the ceiling vent in the entrance foyer had a large accumulation of a black substance… […]

• No harm, potential for more than minimal, widespreadF812Jan 16, 2025

  Based on interview, observation and record review the facility failed prevent cross contamination of drinking glasses during meal service. This failure has the potential to affect all 24 residents residing at the facility. Findings include: On 01/13/24 at 11:43 AM, V4 (Certified Nurse Aide/CNA) delivered drinks to the residents in the dining room by the rim of the glass, where the residents drink from, after touching the kitchen door, the drink cart handle, her jeans, and the handles of several wheelchairs without any hand hygiene performed. On 01/13/24 at 11:40 AM, V4 delivered the drink cart to the hall with the drinks in a tote with ice in the bottom and no lids or covering over the drinks. […]

• No harm, potential for more than minimal, widespreadF921Jan 16, 2025

  Based on observation, interview, and record review the facility failed to provide a safe, sanitary, and clean home-like environment for the residents. This has the potential to affect all 24 residents residing at the facility. Findings including: On 01/13/24 at 12:53 PM, the shower room on the 200 hall had an accumulation of dirt and mildew along the edges between the floor and the wall in the caulk of all three walls of the shower stall. In this same room there is was accumulation of dirt on the floor in between the 1 inch by 1 inch tiles. There is an accumulation of dirt and debris along the edge of the bottom of the toilet where the toilet meets the floor. There was an approximate 2 millimeter black ring inside the toilet bowl. […]

• No harm, potential for more than minimal, widespreadF812Jul 8, 2024

  Based on observation interview and record review the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect all 29 residents currently residing at the facility. Findings Include: The facility Wing Group Assignments provided to this surveyor on 7/6/24 documents 29 residents currently reside at the facility. On 7/6/24 at 9:26 AM, V2 (Director of Nurses) stated the facility freezer went down and they moved all of the food off premises to a dedicated freezer in a secure place at V2's house. V2 stated they maintain the temperature of the freezer. V2 was unable to provide this surveyor with reproducible evidence the temperature of the freezer/food was maintained per current standards of practice. […]