Health inspection·May 14, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of eight residents reviewed (Resident 6). Residents Affected - Some Findings include: The facility policy for medication administration, dated January 15, 2025, indicated that medications are administered in accordance with prescriber orders, and that the following information is checked/verified for each resident prior to administering medications: allergies to medications; and vital signs, if necessary. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 28, 2025, revealed that the resident was cognitively intact, independent with personal care needs, and had diagnoses that included diabetes. Physician's orders for Resident 6, dated February 28, 2025, included an order for the resident to receive one-half tablet of 25 milligrams (mg) of Metoprolol Tartrate (used to treat high blood pressure) twice a day for hypertension (high blood pressure) and to hold the medication if the resident's heart rate is less than 60. Physician's orders, dated March 31, 2025, included an order for the resident to receive six units of Insulin Aspart (rapid acting insulin used to lower blood sugar) three times a day and to hold the medication if the resident's blood glucose (sugar) level was less that 120 milligrams (mg) per deciliter (dL). Review of the Medication Administration Record (MAR) for Resident 6, dated April 2025 and May 2025, revealed that there was no documented evidence that the resident's heart rate was checked twice each day prior to the administration of Metoprolol Tartrate as ordered from April 1, 2025, through May 14, 2025. Review of the MAR also revealed that six units of Insulin Aspart was administered on April 13 at 9:00 a.m. when the resident's blood sugar level was 75 mg/dl, six units of Insulin Aspart was administered on April 17 at 9:00 a.m. when the resident's blood sugar level was 112 mg/dl, six units of Insulin Aspart was administered on May 2 at 9:00 a.m. when the resident's blood sugar level was 98 mg/dl, six units of Insulin Aspart was administered on May 5 at 9:00 a.m. when the resident's blood sugar level was 102 mg/dl, and six units of Insulin Aspart was administered on May 6 at 9:00 a.m. when the resident;s blood sugar level was 104 mg/dl. Interview with the Assistant Director of Nursing on May 14, 2025, at 3:56 p.m. confirmed that the heart rate for Resident 6 should have been assessed prior to the administration of Metoprolol Tartrate; however, it was not. (continued on next page) 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 05/14/2025 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)