Health inspection·March 7, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based upon clinical record review and interview, it was determined the facility failed to ensure residents' physician was notified regarding a resident and failed to ensure residents' physician was notified of a significant weight loss for two of two residents reviewed (Resident 72 and Resident 104). Findings include: Review of Resident 72's clinical progress notes dated July 27, 2024, at approximately 5:45 a.m. revealed Resident 72 suffered a fall out of bed and was found laying on the floor on resident's right side. Further review of Resident 72's clinical progress notes revealed Resident 72 complained of pain upon leg movement. After assessment by facility staff, Resident 72 was returned to bed. Review of clinical documentation failed to reveal evidence that Resident 72''s physician or nurse practitioner were notified of the fall that occurred at 5:45 a.m. Further review of Resident 72's progress notes dated July 27, 2024, at 7:20 a.m. revealed Resident 72 was unable to bear weight and continued to complain of pain in the left lower extremity. Resident 72's nurse practitioner was then notified of the fall that had occurred at 5:45 a.m. and an x-ray was ordered at that time. Review of Resident 72's x-ray report dated July 27, 2024, revealed Resident 72 sustained a fracture of the left femoral (large bone in leg) neck and was subsequently transferred to an acute care facility. Interview with the Director of Nursing on March 7, 2025, at 10:00 a.m. confirmed Resident 72's physician was not notified at the time of Resdient 72's fall with injury. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing Services Previously cited 4/5/2024 Page 1 of 8 396114 396114 03/07/2025 Twin Pines Health Care Center 315 East London Grove Road West Grove, PA 19390

F 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on clinical record reviews, interviews with staff and residents, it was determined that the facility failed to conduct an accurate comprehensive assessment for one of 32 residents reviewed. (Resident 51) Residents Affected - Few Findings include: Clinical record review revealed a quarterly assessment MDS (a minimum data set, which was part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) dated January 1, 2025, that indicated Resident 51 obtained a stage 2 pressure ulcer (a shallow, open sore or an intact or ruptured blister, with a red or pink wound bed caused by prolonged exposure to pressure) while residing in the facility. Further review of Resident 51's MDS revealed a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident 51's clinical records revealed wound care notes dated February 18, 2025, documenting the resident had a skin tear (a traumatic wound that occurs when the top layer of skin separates from the deeper layers) on his/her inner thigh that was being treated with Medihoney (a typical first aide and wound care product) and dressing. Review of Resident 51's clinical records revealed wound care notes dated February 25, 2025, documenting the resident had a skin tear on inner thigh with treatment changed to skin prep. Further review of Resident 51's clinical records revealed wound care notes dated March 4, 2025, documenting the resident had a skin tear on inner thigh that was improving. Review of Resident 51's clinical records revealed that the resident did not have orders for treatment of a stage 2 pressure ulcer. Review of Resident 51's clinical records revealed a care plan last revised on November 15, 2024, documenting the resident is at risk for skin injury related to immobility, paraplegia (paralysis to lower half of body), a history of stage 4 wounds, and a history of tendon release surgery (procedure used to treat muscular skeleton conditions). Interview of Resident 51 on March 5, 2025, at 9:37 am revealed they currently did not have a pressure ulcer. Resident 51 was unable to state the last time he/she had a pressure ulcer. Interview with Register Nurse Employee E4 on March 6, 2025, at 11:58 AM revealed the resident did not have a stage 2 pressure ulcer at the time of the MDS assessment and the resident only had a skin tear. Interview with the MDS Coordinator, Employee E5 on March 6, 2025, at 2:05 p.m., confirmed a data entry error was made on Resident 51's MDS and the resident did not have a facility acquired pressure ulcer at the time of its completion on January 1, 2025. 28 Pa Code 211.12 (d)(1) Nursing services 396114 Page 2 of 8 396114 03/07/2025 Twin Pines Health Care Center 315 East London Grove Road West Grove, PA 19390

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of two residents reviewed regarding oxygen use. (Resident R6) Findings include: Resident R6's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of acute on chronic systolic heart failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), chronic obstructive pulmonary disease, unspecified (a progressive lung disease that makes it difficult to breathe due to obstruction of airflow). Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) upon admission, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. On March 4, 2025, Resident R6 was observed in their room using supplementary oxygen. Review of Resident R6's clinical records revealed the following order administer oxygen via nasal cannula continuously at 2 liters/minute. A review of the current care plan, dated January 21, 2025, found no evidence of a comprehensive, person-centered plan of care addressing oxygen interventions. During an interview on March 7, 2025, at 11:23 a.m., the Director of Nursing (DON), confirmed that Resident R6 had an active order for continuous oxygen and acknowledged that no comprehensive care plan had been developed to address oxygen interventions. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 396114 Page 3 of 8 396114 03/07/2025 Twin Pines Health Care Center 315 East London Grove Road West Grove, PA 19390

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review and interviews with staff, it was determined the facility failed to ensure discharge instructions included all necessary information, including a recapitulation of stay, resident status, medication reconciliation, living arrangements, follow-up care and individualized care instructions, for a one of three closed records reviewed (Resident 111). Findings include: Clinical record review for Resident 111 revealed a Nursing Progress Note, dated December 16, 2024, at 5:19 a.m. which indicated that the resident was admitted to [NAME] County Hospital. Admitting diagnosis was unknown at the time. The hospital nurse was unable to disclose information due to resident request. No further information was noted concerning Resident 111's hospital discharge. Continued review of Resident R111's clinical records revealed no discharge summary documenting the resident's personal belongings were returned, their primary physician information, pharmacy information, housing arrangements, medication list, medication education, medication disposition, disease management education, emergency information, brief medical history, current treatment and therapies, scheduled appointments and tests or contact information for the nursing facility. There was no indication that the information was provided to the resident or his/her family. Interview conducted with Director of Nursing (DON) on March 7, 2025, at 10:05 a.m. when the above information was presented the DON stated the resident had no personal belonging to return or medications to be reconciled and confirmed that no additional discharge instruction information was available for review at the time of the survey for Resident R111. 28 Pa Code 201.25 Discharge policy 28 Pa Code 211.11(e) Resident care plan 396114 Page 4 of 8 396114 03/07/2025 Twin Pines Health Care Center 315 East London Grove Road West Grove, PA 19390

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review and interview, it was determined the facility failed to ensure a fluid restriction, ordered by resident's physician, was monitored for one of one resident reviewed (Resident 99). Residents Affected - Few Findings include: Review of Resident 99's diagnosis list revealed diagnoses including congestive heart failure (CHF excessive body/lung fluid caused by a weakened heart muscle) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Review of Resident 99's clincal record revealed the resident was admitted to the facility on [DATE] with an order for a 2-liter (2L) a day fluid restriction. Review of Resident 99's clinical record failed to reveal evidence that nursing was monitoring Resident 99's daily 2L fluid restriction. Interview with the Director of Nursing on March 7, 2025, at 9:35 a.m. confirmed that nursing was not monitoring Resident 99's 2L fluid restriction as ordered by the physician. This interview further revealed that, per the Director of Nursing, upon review Resident 99 should not have been on a fluid restriction from admission and the fluid restriction was removed on March 7, 2025. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing Services Previously cited 4/5/2024 396114 Page 5 of 8 396114 03/07/2025 Twin Pines Health Care Center 315 East London Grove Road West Grove, PA 19390

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based upon clinical record review and interview, it was determined the facility failed to ensure adequate monitoring of a resident with a significant weight loss (Resident 104). Residents Affected - Few Findings include: Review of Resident 104's diagnosis list revealed diagnoses including protein-calorie malnutrition and adult failure to thrive. Review of Resident 104's weight summary revealed the resident weighed 136.6 pounds on December 8, 2024, and weighed 128.4 pounds on December 22, 2024, indicating a 6 percent weight loss in 14 days. Review of Resident 104's clinical record failed to reveal evidence that Resident 104's physician was not notified of Resident 104's significant weight loss. Review of clinical documentation revealed no re-weight was obtained to ensure accuracy of the weight loss. Interview with Licensed Employee E3 on March 7, 2025, at 9:38 a.m. revealed a re-weight should have been obtained to ensure accuracy of the weight loss. Further interview with Licensed Employee E3 on March 7, 2025 confirmed that Resident 104's physician was not notified of the weight loss and the loss was not address. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services Previously cited 4/5/2024 396114 Page 6 of 8 396114 03/07/2025 Twin Pines Health Care Center 315 East London Grove Road West Grove, PA 19390

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based upon observations, clinical record review and staff interviews, it was determined that the facility failed to ensure fluid restrictions were followed for one of one dialysis resident reviewed. (Resident 16). Residents Affected - Few Findings include: Review of Resident 16's clinical record revealed diagnoses including but not limited to end stage renal disease (ESRD- failure of kidney function to remove toxins from blood) and dementia (general loss of cognitive abilities, including memory). Review of Resident physician's orders revealed an order for daily fluid restriction of 1500 ml daily as follows: Nursing to give 7-3 shift 240 ml; 3-11 shift 660 ml; 11-7 shift 120 ml; dietary daily 480 ml. Review of Resident 16's Fluid Task sheet revealed Resident 16 exceeded the daily fluid restriction allotment as follows: February 11, 2025 - 420 ml; February 14, 2025- 420 ml; February 15, 2025- 540 ml; February 17, 2025 - 300 ml; March 1, 2025 - 780 ml; March 2, 2025 - 420 ml; March 5,2025-180ml; March 6, 2025-300ml. Interview with Director of Nursing on March 7, 2025, at approximately 12:25pm confirmed the above findings. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 396114 Page 7 of 8 396114 03/07/2025 Twin Pines Health Care Center 315 East London Grove Road West Grove, PA 19390

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based upon clinical record review, it was determined the facility failed to monitor for effectiveness or side effects of anti-depressant medication for one of five residents reviewed (Resident 93). Findings include: Review of Resident 93's diagnosis list revealed diagnoses including psychotic disorder with hallucinations, Parkinson's disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), persistent mood disorder and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability.) Review of Resident 93's physician orders revealed order and order dated December 21, 2024, for Lexapro (anti-depressant medication) 10 milligrams (mg) to be administered daily for behaviors and an order dated January 7, 2025, for Wellbutrin (anti-depressant medication) 150 mg to be administered daily. Review of Resident 93's active care plan revealed attempts were to be made for non-pharmaceutical interventions and to monitor Resident 93's mood and behavior while receiving Lexapro and Wellbutrin. Review of Resident 93's clinical record including Resident 93's Medication Administration Record (MAR) failed to reveal evidence that Lexapro and Wellbutrin were being monitored for effectiveness, i.e. reduction in behaviors. Further review of Resident 93's clinical record failed to reveal evidence that Resident 93 was being monitored for side effects of Wellbutrin or Lexapro. Interview with the Director of Nursing on March 7, 2025, at 11:07 a.m. confirmed that no monitoring for effectiveness was completed during Resident 93's use of Wellbutrin or Lexapro. This interview further confirmed that no monitoring for side effects was completed for the use of Lexapro and Wellbutrin. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services 396114 Page 8 of 8