Inspection Reports for Twin Towers
5343 Hamilton Ave, Cincinnati, OH 45224, United States, OH, 45224
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
72 residents
Based on a August 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 72
Deficiencies: 7
Aug 30, 2024
Visit Reason
Routine inspection to assess compliance with regulations related to resident care, medication administration, infection control, and food safety at Twin Towers nursing home.
Findings
The facility failed to notify physicians about bleeding during urinary catheter changes for Resident #49, failed to follow physician orders for catheter care, and did not ensure nursing staff competency in catheter care. Medication errors were identified for Residents #29 and #49, and pharmacy recommendations were not implemented for Residents #58 and #72. Food safety violations included improper storage of frozen foods and failure to wear beard guards. The facility also failed to ensure staff were fit tested for respirators required for COVID-19 precautions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to notify physician of bleeding during indwelling urinary catheter changes for Resident #49. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff followed physician orders for indwelling urinary catheter care for Resident #49. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nursing staff possessed competencies necessary for indwelling urinary catheter care for Resident #49. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pharmacy recommendations were implemented for Residents #58 and #72 regarding unnecessary medications. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate was 16.13% due to incorrect administration of medications and supplements for Residents #29 and #49. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper food safety practices including wearing beard guards and proper storage of frozen foods. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff were fit tested for respirators required for respiratory protection when working with COVID-19 positive residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 72
Medication error rate: 16.13
Medication errors: 5
Medication administration opportunities: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to urinary catheter care and failure to notify physician of bleeding |
| Physician #2 | Physician | Named in findings related to urinary catheter care and medication management |
| RN #14 | Registered Nurse | Named in medication administration errors |
| Director of Nursing | Director of Nursing | Interviewed regarding catheter care, medication errors, staff competencies, and infection control |
| Administrator | Administrator | Interviewed regarding expectations for medication administration, food safety, and infection control |
| Pharmacist | Pharmacist | Interviewed regarding medication regimen reviews and medication errors |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding pharmacy recommendations and medication changes |
| Prep [NAME] #6 | Food Preparation Staff | Observed preparing food without beard cover |
| STNA #8 | State Tested Nurse Aide | Observed and interviewed regarding PPE use and lack of respirator fit testing |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding lack of respirator fit testing |
| LPN #10 | Licensed Practical Nurse | Interviewed regarding lack of respirator fit testing |
Inspection Report
Routine
Census: 76
Deficiencies: 2
Nov 3, 2022
Visit Reason
The inspection was conducted to evaluate compliance with nutritional and food safety standards, including proper preparation and serving of puree diets and sanitation practices in food handling and storage.
Findings
The facility failed to provide puree foods as planned by a Registered Dietitian, including incorrect portion sizes and missing items for residents on puree diets. Additionally, multiple sanitation violations were observed, including improper food labeling, glove use, and dishwasher chemical testing, potentially affecting all residents receiving food.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide puree foods as planned by a Registered Dietitian, including incorrect serving utensil sizes and missing puree food items for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label and date foods, accurately test dishwasher sanitation, and use hand gloves in a sanitary manner during food service. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 76
Undated pies: 12
Undated egg salad containers: 4
Dishwasher chlorine level: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DS #410 | Diet Server | Named in findings related to incorrect serving utensil use, missing puree food items, and dishwasher chemical testing |
| Diet Manager #400 | Diet Manager | Verified incorrect puree serving portions and missing puree pudding; stated chlorine test strip was not available |
| DS #420 | Diet Server | Named in findings related to improper glove use during food service |
| DS #450 | Diet Server | Named in findings related to improper glove use during food service |
| Chef #510 | Chef | Verified sanitation violations including undated and unlabeled foods and improper ice scoop storage |
| Chef #500 | Chef | Named in findings related to handling food processor with contaminated gloves |
Inspection Report
Annual Inspection
Census: 82
Capacity: 93
Deficiencies: 4
Mar 5, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including staff background checks, resident care practices, nutritional services, and infection control.
Findings
The facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment, failed to provide appropriate treatment for resident edema including daily weights and application of compression stockings, failed to serve lunch according to the menu and recipe, and failed to properly disinfect blood glucose monitoring equipment between resident use.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure all staff were checked against the Nurse Aide Registry prior to employment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure elastic compression stockings were in place and daily weights obtained for edema as ordered for Resident #11. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve lunch according to the recipe and menu, missing toppings for soft beef tacos served to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure blood glucose monitoring equipment was properly disinfected between use of residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 93
Residents affected: 82
Residents affected: 1
Residents affected: 82
Residents affected: 1
Residents observed for medication administration: 9
Residents identified with blood glucose monitoring: 4
Weight tracking missing days: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Human Resource Manager #70 | Human Resource Manager | Verified employees were not checked on the State Nurse Aide Registry |
| Administrator | Administrator | Confirmed facility had not completed State Nurse Aide Registry checks on certain employees |
| Licensed Practical Nurse #75 | Licensed Practical Nurse | Verified Resident #11 did not have ACE wraps or elastic compression stockings in place as ordered |
| Director of Nursing | Director of Nursing | Confirmed Resident #11 did not have daily weights obtained as ordered |
| Dining Director #300 | Dining Director | Reviewed taco menu item and verified missing toppings |
| Licensed Practical Nurse #82 | Licensed Practical Nurse | Observed using and cleaning blood glucose monitoring device improperly |
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