Pennsylvania Department of Health
TWIN PINES HEALTH CARE CENTER
Patient Care Inspection Results

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TWIN PINES HEALTH CARE CENTER
Inspection Results For:

There are  106 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
TWIN PINES HEALTH CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on April 5, 2024, it was determined that Twin Pines Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.
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 Plan of Correction:


483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:



Based on observation, it was determined that the facility failed to provide privacy and confidentiality of residents ' personal information on two of four nursing units (South and East).

Findings include:

Observation on the East unit on April 2, 2024, at approximately 10:00 a.m. revealed the computer on the medication cart was left unattended with Resident 85's physician orders displayed. Several residents and other staff were noted nearby the medication cart.

Observation on the South unit on April 3, 2024, at approximately 8:00 a.m. revealed the computer on the medication cart was left unattended with Resident 59's physician orders displayed. Several residents and other staff were noted nearby the medication cart.

Observation on the East unit on April 5, 2024, at approximately 8:30 a.m. revealed the computer on the medication cart was left unattended with Resident 29's physician orders displayed. Several residents and other staff were noted nearby the medication cart.

Interview with the Director of Nursing on April 5, 2024, at 10:20 a.m. confirmed the above findings.

28 Pa. Code: 201.18 (e)(1) Management

28 Pa. Code: 201.29 (j) Resident rights

28 Pa. Code: 211.5 (f) Clinical records



 Plan of Correction - To be completed: 04/30/2024

1. Upon notification that Medication Cart Computers were left unattended with observable resident information displayed the Director of Nursing (DON) completed rounds, ensuring that all unattended medication computers were closed.


2. All residents have the potential to be affected. On 4/5/2024 the DON and/or designee observed all medication carts and publicly accessible computers to ensure that they were shut down if unattended. No issues were identified.


3. To prevent the potential for reoccurrence the DON and/or designee will educated a licensed staff on HIPAA compliance with emphasis on securing medication carts while unattended to prevent potential breaches.


4. To monitor and maintain ongoing compliance the DON and/or designee will conduct an audit of all medication cart computers to ensure protected information is appropriately secured 1 time a week for 3 months. If necessary, the computer will be secured and the responsible nurse immediately re-educated. Findings will be presented to the QAPI committee for continued review and recommendation.

Responsible party will be the Director of Nursing and or designee


483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:
Based upon clinical record review, it was determined the facility failed to complete discharge summary on the day of planned discharge for one of three residents reviewed (Resident 109).

Findings include:

Review of Resident 109's clinical record revealed Resident 109 was admitted to the facility on December 8, 2023, and was discharged to home on March 23, 2024.

Review of Resident 109's clinical record failed to reveal a discharge summary completed on March 23, 2024, the day of a planned discharge.

The above information was conveyed to the Nursing Home Administrator on April 5, 2024, at 11:00 a.m.

28 Pa. Code 211.5(f) Clinical Records


 Plan of Correction - To be completed: 04/30/2024

1. A discharge summary was completed for R109.


2. All discharged residents have the potential to be affected. On 4/15/2024 the Social Services Director (SSD) audited all discharges from date of survey exit to ensure a discharge summary was present within the medical record. Where necessary a discharge summary was completed.


3. To prevent the potential for reoccurrence the Nursing Home Administrator (NHA) educated the Social Services Department on the discharge process with emphasis on ensuring a discharge summary is completed as required.

4. To monitor and maintain ongoing compliance the SSD and/or designee will review all resident discharges 1 time weekly for 3 months to ensure that a discharge summary is present. If necessary, a discharge summary will be completed, and the responsible person reeducated. Findings will be presented to the QAPI committee for continued review and recommendation.

Responsible party is the Director of Social Work or Designee

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain 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.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on a comprehensive review of clinical records, observations, and interviews with residents and staff, it was determined that the facility failed to consistently implement and maintain infection control practices, thereby risking the potential spread of infection for one resident requiring contact precautions (a method to prevent the transmission of infectious agents spread by direct or indirect contact with the patient or the patient's environment) out of 32 residents sampled (Resident 90).

Findings include:

Review of the facility's policy "Transmission-Based Precautions and Isolation Policy" with a revision date of March 3, 2024, states that "Contact precautions also apply where the presence of excessive wound drainage, urine, or fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Personal Protective Equipment (PPE) recommended includes gloves and gowns."

Review of the "CONTACT PRECAUTIONS" sign reveals instructions for all personnel to clean their hands before entering and leaving the room, and for providers and staff to don gloves and gowns before room entry and discard them before room exit.

A review of Resident 90's clinical medical record revealed a progress note dated March 28, 2024 at 1:01 p.m. stating Resident 90's urinary analysis (UA) came back positive for Extended Spectrum Beta-Lactamase e-coli (ESBL, are enzymes produced by certain bacteria, including Escherichia coli that make bacteria resistant to certain antibiotic medicines) (Escherichia-coli, is a group of bacteria that can cause infections in one's gut, urinary tract and other parts of your body).

During a tour of nursing unit East on April 2, 2024, at 10:31 a.m., it was observed that the PPE station, including gloves, gowns, and face shields, was available, but the contact precaution sign was placed face down on top of the container outside Resident 90's room.

Additional observations conducted on nursing unit East on April 2, 2024, at 10:33 a.m. revealed three nursing staff performing incontinence care (helping an individual with any type of urinary or bowel leakage to maintain their health, and wellbeing) on Resident 90 with only gloves on.
Observations conducted on April 3, 2024, at 9:36 a.m., witnessed a nursing staff exiting Resident 90's room holding soiled bed linens without wearing a gown.

Additional observations of Resident 90's room on April 3, 2024, at 9:39 a.m. observed two nursing staff entering Resident 90's room without washing their hands or dawning PPE. At 9:35 a.m. licensed practical nurse (LPN) licensed employee (E4) exited Resident 90's room without washing her hands.

Interview conducted with licensed employee E4 on April 3, 2024, at 9:35 a.m. revealed E4 was unaware resident 90 was on contact precautions or that Resident 90's UA returned positive for ESBL E-coli.
Interview conducted with Infection Preventionist (IP) licensed employee (E3) on April 3, 2024, at 1:18 p.m. confirmed Resident 90 is on contact precaution and that all staff need adhere to the facility's transmission-based precautions and isolation policy.

The above information was confirmed by licensed employee E3 on April 3, 2024, at 1:24 p.m.

28 Pa. Code 211.10 (a)(d) Resident care policies

28 Pa. Code 211.12 (c)(d)(1)(2)(5) Nursing Services.



 Plan of Correction - To be completed: 04/30/2024

1. Upon being notified that the Contact Isolation sign posted on R90's bedroom threshold had fallen the DON secured the sign to the door. Employee E4 was immediately educated on Isolation Precaution Requirements with emphasis on Contact Isolation procedures. E4 was also educated on the correct procedure for maintaining effective hand hygiene practices.


2. All residents have the potential to be affected. On 4/3/2024 the Housekeeping Director and/or designee cleaned all high touch surfaces outside of R90's room to ensure inadvertent bacterial communication would not occur.

3. To prevent the potential for reoccurrence the DON and/or designee educated all staff on Isolation Precautions with emphasis on Contact Isolation Precautions. All staff was also educated on effective hand hygiene practices.

4. To monitor and maintain ongoing compliance the DON and/or designee will monitor all isolation signage 1 time weekly for 3 months. If necessary, signs will be hung per precautionary guidelines and the responsible person reeducated. The DON and/or designee with also monitor PPE utilization as required by Contact Isolation parameters 3 times weekly for 3 months. If necessary, the area outside of the affected room will be sanitized and the responsible person reeducated. The DON and/or designee will observe hand hygiene practices to ensure compliance is maintained 3 times weekly for 3 months. Where necessary the responsible person will be reeducated. Findings will be presented to the QAPI committee for continued review and recommendation.

Responsible party is the Director of Nursing or Designee

205.63(c) LICENSURE Plumbing & Piping Systems-Hot Water Outlets.:State only Deficiency.
(c) Hot water outlets accessible to residents shall be controlled so that the water temperature of the outlets does not exceed 110F.

Observations:

Based on observations and staff interview it was determined the facility failed to maintain water temperatures below 110 degrees Fahrenheit on all units of the facility. (West, North, East, South)

Findings Include:

Observations in the bathroom on April 4, 2024 at 1:00 p.m. by the main entrance revealed the water observed to be very warm.

Interview with the Nursing Home Administrator and Maintenance Director Employee E2 on April 4, 2024 at 1:15 p.m. revealed there were no known issues with the water system currently in the facility.

Water temperatures were obtained with the Maintenance Director in the follow rooms with the following temps on April 4, 2024 Between 1:20 to 1:45 p.m.

West Shower Room- 125 degrees
Room 123- 111 degrees
Room 119- 119.5 degrees

North Shower Room- 122.4 degrees
Room 235- 120.6 degrees
Room 225- 118.8 degrees

Room 460- 116.9 degrees
Room 466- 119.2 degrees

Room 340- 116.2 degrees


Interview with the Maintenance Director on April 4, 2023 at 1:45 p.m. confirmed the facility failed to maintain water temperatures below 110 degrees Fahrenheit.



 Plan of Correction - To be completed: 04/05/2024

1) Upon becoming aware of the water temperatures being too warm at approximately 1:45PM all showering/hand washing/water use for hygiene was halted and postponed and sanitizers were distributed to all of the nursing staff including CNA/LPNs. Both gel based hand sanitizers and hand wipe format sanitizers were placed with each nurse, and at each nursing station. Nurses were informed of the issue and instructed to not use the water until it was deemed safe and all clear, and in the meantime only utilize the sanitizer products. They were informed an announcement would come overhead and walking rounds would be completed once the issue was remedied so that they would be aware they could resume showers and hand washing at the sinks.

2) A call was made immediately to our mechanical services company Cook's Service co. and they had a technician on site by 2:15 to assess what was causing the issue of the temperature fluctuation. It was determined that the mixing valve had failed and this issue was only visible once the mixing valve was removed. It was replaced completely by 4PM. Water temperatures were being taken prior to and after the repair. Prior to repair completing temperatures were still hovering around 110-115 degrees at around 3PM. At 4pm Temps were shown to be decreasing and reading 104-108 throughout the facility. Once repair was made and valve was replaced by 5PM temperatures were around 105 degrees and within acceptable limits. This testing was repeated at 5:30PM, 6:00PM and 6:30PM to demonstrate the water was stable and holding a maximum temperature of 103, and dropping slightly at that point. Residents and staff were informed at 6:30PM via overhead page, and walking rounds by both admin and maintenance director that the water was ok to use for showers and handwashing after the repair was completed, and temperatures had returned and remained at a compliant and safe temperature. All post dinner evening showers were completed by our evening staff without issue.

3) At 7:30PM temperatures were again tested in all units to ensure continued stable temperature. Readings of temperatures were taken building wide and show a temperature of 97-100 degrees building wide and no temperatures fluctuating. Temps were again taken at 10:30PM to ensure no issues, and none were found as temps held steady at around 100 degrees with a range of 97-100 degrees again. The next morning at 5:30AM temperatures were taken by both Twin Pines staff as well as the owner of Cooks Service Co. The temperatures had shown no fluctuation or settling in either direction and stayed steady between 97-100 degrees.

4) Ongoing daily weekly water temperature audits will be taken over the course of a year as scheduled to ensure water temperature falls in acceptable parameters. Results and findings of these daily audits and temperature checks will be reported to the QAPI committee monthly. The Director of Maintenance will continue to check water temps in 15 different locations five days a week ongoing.

Responsible party is the Director of Maintenance

211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on review of facility staffing data, it was determined that the facility failed to ensure a minimum of one Licensed Practitioner Nurse per 25 residents on day shift and one Licensed Practitioner Nurse per 30 residents on evening shift for three weeks of facility staffing reviewed (Weeks of December 24, 2023, February 11. 2024 and March 29, 2024). Further review of facility staffing data revealed the facility failed to ensure a minimum of one Registered Nurse per 250 residents on night shift for one of three weeks reviewed (week of March 29, 2024).


Findings include:

Review of facility census data indicated that on 12/24/23, the facility census was 107 which required 4.28 LPNs during the day shift.

Review of the nursing time schedules revealed 4.25 LPNs provided care on the day shift on 12/24/23. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/11/24, the facility census was 109 which required 4.36 LPNs during the day shift.

Review of the nursing time schedules revealed 4 LPNs provided care on the day shift on 2/11/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/11/24, the facility census was 109 which required 3.63 LPNs during the evening shift.

Review of the nursing time schedules revealed 3.00 LPNs provided care on the day shift on 2/11/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/12/24, the facility census was 107 which required 4.28 LPNs during the day shift.

Review of the nursing time schedules revealed 4 LPNs provided care on the day shift on 2/12/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/12/24, the facility census was 107 which required 3.57 LPNs during the evening shift.

Review of the nursing time schedules revealed 3 LPNs provided care on the evening shift on 2/12/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/13/24, the facility census was 106 which required 4.24 LPNs during the day shift.

Review of the nursing time schedules revealed 2 LPNs provided care on the day shift on 2/13/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/16/24, the facility census was 107 which required 4.28 LPNs during the day shift.

Review of the nursing time schedules revealed 4.13 LPNs provided care on the day shift on 2/16/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/17/24, the facility census was 107 which required 4.28 LPNs during the day shift.

Review of the nursing time schedules revealed 4 LPNs provided care on the day shift on 2/17/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/29/24, the facility census was 110 which required 4.40 LPNs during the day shift.

Review of the nursing time schedules revealed 3.16 LPNs provided care on the day shift on 3/29/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/29/24, the facility census was 110 which required 3.67 LPNs during the evening shift.

Review of the nursing time schedules revealed 3.06 LPNs provided care on the evening shift on 3/29/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/30/24, the facility census was 109 which required 4.36 LPNs during the day shift.

Review of the nursing time schedules revealed 3.06 LPNs provided care on the day shift on 3/30/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/31/24, the facility census was 109 which required 4.36 LPNs during the day shift.

Review of the nursing time schedules revealed 4.03 LPNs provided care on the day shift on 3/31/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/31/24, the facility census was 109 which required 3.63 LPNs during the evening shift.

Review of the nursing time schedules revealed 3.03 LPNs provided care on the evening shift on 3/31/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 4/1/24, the facility census was 108 which required 4.32 LPNs during the day shift.

Review of the nursing time schedules revealed 3 LPNs provided care on the day shift on 4/1/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 4/3/24, the facility census was 108 which required 4.32 LPNs during the day shift.

Review of the nursing time schedules revealed 4 LPNs provided care on the day shift on 4/3/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 4/4/24, the facility census was 108 which required 4.32 LPNs during the day shift.

Review of the nursing time schedules revealed 4 LPNs provided care on the day shift on 4/4/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 4/4/24, the facility census was 108 which required 3.60 LPNs during the evening shift.

Review of the nursing time schedules revealed 3 LPNs provided care on the evening shift on 4/4/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 4/3/24, the facility census was 108 which required 1 RN during the night shift.

Review of the nursing time schedules revealed 0.97 RNs provided care on the night shift 4/3/24.

Interview with the Nursing Home Administrator on April 5, 2024, at 2:00 p.m. confirmed that the nursing staffing ratios were not met on the above days.






 Plan of Correction - To be completed: 04/30/2024

1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regards to clocking in and out.

2) Staffing reviewed daily to ensure vacant shifts are filled to meet the ratio requirements, and the hours set which have been determined by census and the ratio requirement are accurate and all efforts are made to replace, fill, and or meet all necessary requirements.

3) Root-Cause Analysis demonstrates that call offs close to shift time, agency cancellations, or no shows were unable to be replaced. Staff re-educated on call of parameters as well as providing education to managing staff.

4) NHA and or designee to review staffing daily to ensure ratio requirement is met at 100 percent daily x 3 weeks, then weekly x3 weeks. The results will be reported to the facilities QAPI committee for continued review and revision.

Responsible party is the Administrator


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