Pennsylvania Department of Health
 TWINBROOK HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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TWINBROOK HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  127 surveys for this facility. Please select a date to view the survey results.

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TWINBROOK HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on December 23, 2024, it was determined that Twinbrook Healthcare and Rehabilitation Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to follow physician's orders related to laboratory blood draws for three of the four residents reviewed for laboratory testing (Residents R1, R2, and R3).

Findings include:

Review of a facility policy entitled, "Provision of Physician Ordered Services" dated 11/08/24, revealed "Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders."

Review of Resident R1's clinical record revealed an admission date of 7/31/24, with diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that make it difficult to breath), muscle weakness, and respiratory failure.

Review of Resident R1's clinical record revealed a physician's order dated 12/18/24, for a follow-up Comprehensive Metabolic Panel (CMP-a group of laboratory tests that measure various substances in the blood to assess overall health and detect potential medical conditions) and a Complete Blood Count (CBC) with differential (a blood test that measures the number and types of various blood cells) to be obtained on 12/19/24. Resident R1's clinical record revealed the CBC was drawn on 12/20/24, and lacked evidence that the CMP was drawn.


Review of Resident R2's clinical record revealed an admission date of 2/08/22, with diagnoses that included COPD, respiratory failure, and dementia (a group of memory, thinking, and social symptoms that interfere with daily living).

Review of Resident R2's clinical record revealed a physician's order dated 10/20/24, for a routine potassium level to be obtained on every first and third Monday of the month. Resident R2's clinical record lacked evidence that the potassium level blood draws were collected as ordered by the physician in December 2024.


Review of Resident R3's clinical record revealed an admission date of 6/07/24, with diagnoses that included type 2 diabetes (condition where the body does not make enough insulin), muscle weakness, and lack of coordination.

Review of Resident R3's clinical record revealed a physician's order dated 12/18/24, for a routine CMP and CBC with differential to be obtained on 12/19/24. Resident R3's clinical record lacked evidence that the CMP and CBC with differential were collected as ordered by the physician.

During an interview on 12/22/24, at approximately 1:00 p.m. the Director of Nursing confirmed that Residents R1, R2, and R3's laboratory blood draws listed above were not obtained as ordered by the physician.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services






 Plan of Correction - To be completed: 01/20/2025

Twinbrook Healthcare acknowledges the importance of adhering to physician orders to ensure quality care and has taken immediate corrective actions to address the cited deficiencies. Following identification of the missed laboratory draws for Residents R1, R2, and R3, the attending physicians were promptly notified, and new orders for the required laboratory tests were obtained and completed. A review of the clinical records confirmed that no adverse reactions occurred as a result of the missed labs for the residents cited.

To ensure ongoing compliance, the Director of Nursing (DON) or designee conducted a full audit of all current lab orders for facility residents to verify that laboratory tests were completed as ordered. No additional issues were identified during the audit. Moving forward, lab requests will be reviewed by way of electronic medical record generated reports of all physician ordered labs three (3) times a week for four (4) weeks and then monthly for two (2) months by the DON or designee to confirm compliance with physician orders. Any discrepancies will be immediately addressed, and findings will be reviewed in Quality Assurance Performance Improvement (QAPI) meetings.

In addition, all nursing staff have been re-educated on the facility's policy for taking and complying with lab draw orders. Education sessions, led by the DON or designee, emphasized the importance of following physician orders for diagnostic testing and maintaining accurate documentation. Education completed by 1/20/2025, and compliance will be reinforced through ongoing training during new staff orientation and regular in-service sessions.

These measures have been implemented to ensure adherence to professional standards of practice and the delivery of quality, person-centered care. Full implementation of this Plan of Correction was completed by 1/20/2025.

483.50(a)(1)(i) REQUIREMENT Laboratory Services: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.
§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.
Observations:

Based on review of facility policy, clinical records, and facility documents, observations, and staff interview, it was determined that the facility failed to ensure an organized system and adequate supplies were in place for timely and accurate laboratory services for four of four residents reviewed for laboratory testing (Residents R1, R2, R3, and R4).

Findings include:

Review of a facility policy entitled, "Laboratory Services and Reporting" dated 11/08/24, revealed "The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of the services. Should the facility provide its own laboratory services, the services must meet the applicable requirement for laboratories."

Observations made on 12/22/24, at approximately 10:45 a.m. in the laboratory supply room revealed the facility lacked adequate supplies to obtain laboratory blood draws in-house.

Review of Resident R1's clinical record revealed an admission date of 7/31/24, with diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that make it difficult to breath), muscle weakness, and respiratory failure.

Review of Resident R1's clinical record revealed a physician's order dated 12/18/24, for a follow-up Comprehensive Metabolic Panel (CMP-a group of laboratory tests that measure various substances in the blood to assess overall health and detect potential medical conditions) and a Complete Blood Count (CBC) with differential (a blood test that measures the number and types of various blood cells) to be obtained on 12/19/24. Resident R1's clinical record revealed the CBC was drawn on 12/20/24, and lacked evidence that the CMP was drawn.

Review of facility documents (laboratory binder) on 12/22/24, at approximately 11:00 a.m. revealed a laboratory order sheet for Resident R1 which was incomplete.

Review of Resident R2's clinical record revealed an admission date of 2/08/22, with diagnoses that included COPD, respiratory failure, and dementia (a group of memory, thinking, and social symptoms that interfere with daily living).

Review of Resident R2's clinical record revealed a physician's order dated 10/20/24, for a routine potassium level to be obtained on every first and third Monday of the month. Resident R2s clinical record lacked evidence that the potassium level blood draws were collected as ordered by the physician in December 2024.

Review of facility documents (laboratory binder) on 12/22/24, at approximately 11:00 a.m. revealed a laboratory order sheet for Resident R2 which was incomplete.

Review of Resident R3's clinical record revealed an admission date of 6/07/24, with diagnoses that included type 2 diabetes (condition where the body does not make enough insulin), muscle weakness, and lack of coordination.

Review of Resident R3's clinical record revealed a physician's order dated 12/18/24, for a routine CMP and CBC with differential to be obtained on 12/19/24. Resident R3's clinical record lacked evidence that the CMP and CBC with differential were collected as ordered by the physician.

Review of facility documents (laboratory binder) on 12/22/24, at approximately 11:00 a.m. revealed a laboratory order sheet for Resident R3 which was incomplete.

Review of Resident R4's clinical record revealed an admission date of 3/09/24, with diagnoses that included type 2 diabetes, muscle weakness, and cognitive communication deficit (difficulty communicating effectively related to impairments).

Review of Resident R4's clinical record revealed a routine order for Thyroid Stimulating Hormone (TSH-measures how the thyroid is working), Cortisol level (measures the amount of cortisol in the blood), Basic Metabolic Panel (BMP-blood test that measures several key substances in the blood), CBC with differential, and a CMP were drawn on 12/09/24, and sent to Associated Clinical Laboratories (ACL). ACL then requested a redraw for the routine Adrenocorticotropic Hormone (ACTH-test to monitor the pituitary and adrenal glands) and B-type natriuretic peptide (BNP-monitors the level of the hormone called BNP in the blood) to be completed on 12/10/24. Resident R4's clinical record lacked evidence of the redraw for the ACTH and BNP being completed.

Review of facility documents (laboratory binder) on 12/22/24, at approximately 11:00 a.m. revealed a laboratory order sheet dated 12/10/24, for Resident R4's redraw related to the ACTH and BNP was incomplete.

During an interview on 12/22/24, at approximately 1:00 p.m. the Director of Nursing confirmed that Residents R1, R2, R3, and R4's laboratory blood draws listed above were not obtained in a timely and/or accurate manner related to the facilities absence of an organized laboratory system and insufficient laboratory supplies.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services




 Plan of Correction - To be completed: 01/20/2025

Twinbrook Healthcare recognizes the importance of timely and accurate laboratory services to meet the needs of our residents. Following identification of the deficiencies cited, immediate corrective actions were taken to address the issues related to lab supply shortages and the organization of laboratory services. The laboratory supply room was promptly restocked to ensure an adequate supply of materials necessary for in-house blood draws. Additionally, nursing staff were re-educated by Director of Nursing (DON)/designee on the process for monitoring and replenishing laboratory supplies, and supply levels will be audited weekly for four [4] weeks and monthly for two [2] months by the Director of Nursing (DON) or designee to ensure availability of necessary items.

Regarding the residents cited in the findings, the attending physicians for Residents R1, R2, R3, and R4 were immediately notified of the missed laboratory draws, and the labs were obtained and completed. A thorough audit of all current laboratory orders for facility residents was conducted to ensure compliance, and no further issues were identified. Weekly reviews of lab requests will be conducted via use of electronic medical records generated reports of physician ordered labs three (3) times a week for four [4] weeks, followed by monthly reviews for two [2] months, to confirm that laboratory tests are being ordered, documented, and completed as required.

All nursing staff have been re-educated on the facility's policy for taking and complying with lab draw orders. This education, conducted by the DON or designee, emphasized the importance of adhering to physician orders, maintaining accurate documentation, and ensuring timely completion of all laboratory tests. Education completed by 1/20/2025, and compliance will continue to be reinforced through ongoing education during regular staff in-service sessions. Any discrepancies will be immediately addressed, and findings will be reviewed in Quality Assurance Performance Improvement (QAPI) meetings.

Finally, it has been verified that no adverse reactions occurred as a result of the missed laboratory draws for the residents cited in this finding. Full implementation of this Plan of Correction will be completed on 1/20/2025.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to maintain a homelike environment for one of nine residents reviewed (Resident R5).

Findings include:

Review of a facility policy entitled "Safe and Homelike Environment" dated 11/08/24, revealed "Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment."

Observation of Resident R5's room on 12/22/24, at approximately 10:30 a.m. revealed the baseboard heating system was detaching from the wall creating a noticeable gap between the baseboard heating system and the wall.

During an interview on 12/22/24, at approximately 1:08 p.m. the Director of Nursing confirmed that the gap between the baseboard heating system and the wall was not homelike and should have been repaired or replaced.

28 Pa. Code 201.18 (e)(2.1) Management

28 Pa. Code 201.14(a) Responsibility of licensee



 Plan of Correction - To be completed: 01/20/2025

This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.

Twinbrook Healthcare has taken immediate corrective action to address the cited deficiency and ensure the facility provides a safe, clean, comfortable, and homelike environment for all residents. The gap between the baseboard heating system and the wall in Resident R5's room was repaired on 12/22/24. Additionally, a full-house audit was conducted by the Maintenance staff and was completed on the same day to verify that all baseboard heating systems throughout the facility were securely attached to the walls. No other issues were identified during this audit.

To prevent recurrence, Twinbrook Healthcare has implemented an inspection process for all baseboard heating systems to check for proper attachment to walls to maintain a homelike environment to be completed weekly for two [2] weeks and monthly for two [2] months. These inspections will be conducted by the Maintenance Director or a designated staff member for a period of two months, with findings reviewed in Quality Assurance Performance Improvement (QAPI) meetings. Any identified issues will be addressed promptly.

Maintenance Director or designee to re-educate all staff on the facility's policy regarding reporting maintenance concerns, including the importance of promptly notifying the Maintenance Department of any issues affecting the safety, cleanliness, or comfort of the environment. Re-education sessions to be completed by 1/20/2025 and ongoing education will be provided during orientation for new hires and as part of regular staff training.

Through these actions, Twinbrook Healthcare reaffirms its commitment to maintaining a high standard of living for its residents, ensuring their safety and comfort at all times. Full implementation of this Plan of Correction completed by January 20, 2025.

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