Health inspection·December 3, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify to update the admitting facility with information about laboratory testing and results for one of three residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 27, 2024, indicated that the resident was cognitively intact, usually understood and could sometimes understand, required assistance from staff for his daily care needs, was always incontinent of bowel and bladder, and had diagnoses that included debilitating cardiorespiratory conditions. Physician orders for Resident 2, dated September 4, 2024, included an order for Clostridioides difficile (C-diff - infectious bacteria that causes diarrhea, an inflammation of the colon, and can be life-threatening) toxin stool for frequent watery stools. A nursing note for Resident 2, dated September 4, 2024, at 5:20 p.m., indicated that the resident had recurrent watery stools throughout the shift. The stool was brown, unformed, watery, and had a fowl odor. New orders were received to collect and send the stool for C-Diff toxin. Laboratory results for Resident 2, dated September 5, 2024, at 9:55 p.m., indicated that she was positive for the C difficile toxin. A nursing note for Resident 2, dated September 6, 2024, at 11:39 a.m., indicated that the resident had discharged to another facility at 11:00 a.m. There was no documented evidence in Resident 2's clinical record as well as referral information sent to the admitting facility included current laboratory testing or laboratory results of C-diff. Interview with the Director of Nursing on December 3, 2024, at 3:39 p.m. confirmed that there was no documented evidence that Resident 2's admitting facility was updated about current laboratory testing or laboratory results of C-diff. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395500 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395500 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Lakes Rehabilitation and Healthcare Center 227 Sand Hill Road Greensburg, PA 15601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)