Twin Pines Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Grove, Pennsylvania.
- Location
- 315 East London Grove Road, West Grove, Pennsylvania 19390
- CMS Provider Number
- 396114
- Inspections on file
- 20
- Latest survey
- March 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Twin Pines Health Care Center during CMS and state inspections, most recent first.
The facility failed to notify the physician of a resident who fell from bed and sustained a fracture, delaying necessary medical intervention. Additionally, the physician was not informed of another resident's significant weight loss.
A facility failed to conduct an accurate comprehensive assessment for a resident, as a quarterly MDS incorrectly indicated a stage 2 pressure ulcer. Clinical records and staff interviews confirmed this was a data entry error, as the resident only had a skin tear, which was being treated and improving.
A facility failed to create a comprehensive care plan for a resident using supplementary oxygen. The resident, with heart failure and COPD, had an order for continuous oxygen via nasal cannula, but the care plan lacked interventions for oxygen use. The DON confirmed the oversight.
A facility failed to monitor a physician-ordered 2-liter per day fluid restriction for a resident with CHF and dementia. The clinical record lacked evidence of monitoring, and the DON confirmed the oversight. It was later determined that the resident should not have been on a fluid restriction, leading to its removal.
A resident with protein-calorie malnutrition and adult failure to thrive experienced a 6% weight loss over 14 days. The facility failed to notify the resident's physician or obtain a re-weight to verify the accuracy of the weight loss. An interview with a licensed employee confirmed these oversights.
A facility failed to follow fluid restrictions for a resident with ESRD and dementia, resulting in excess fluid intake on multiple occasions. The resident's daily fluid limit was exceeded on several dates, as confirmed by the DON.
The facility failed to maintain the privacy and confidentiality of residents' personal information on two nursing units. Computers on medication carts were left unattended with residents' physician orders displayed on multiple occasions, with several residents and staff nearby. The DON confirmed these findings.
The facility failed to complete a discharge summary on the day of a planned discharge for a resident. The resident was admitted and later discharged to home, but the discharge summary was not completed on the planned discharge day. This was communicated to the Nursing Home Administrator.
The facility failed to implement and maintain infection control practices for a resident with ESBL E. coli. Observations showed staff not following proper PPE protocols, including not wearing gowns and not washing hands. An LPN was unaware of the resident's contact precautions status, and the Infection Preventionist confirmed the lapses in adherence to the facility's policies.
Failure to Notify Physician of Resident's Fall and Weight Loss
Penalty
Summary
The facility failed to notify the physician of two residents regarding significant events affecting their health. Resident 72 experienced a fall from bed at approximately 5:45 a.m., was found on the floor, and complained of pain upon leg movement. Despite these events, there was no evidence that the resident's physician or nurse practitioner was notified immediately. It was only at 7:20 a.m., after the resident was unable to bear weight and continued to complain of pain, that the nurse practitioner was informed, and an x-ray was ordered. The x-ray revealed a fracture of the left femoral neck, leading to the resident's transfer to an acute care facility. The Director of Nursing confirmed that the physician was not notified at the time of the fall. Additionally, the facility failed to notify the physician of another resident, Resident 104, regarding a significant weight loss, although specific details about this resident's condition and the timeline of events were not provided in the report.
Inaccurate MDS Assessment Due to Data Entry Error
Penalty
Summary
The facility failed to conduct an accurate comprehensive assessment for a resident, identified as Resident 51, as required by regulations. A quarterly assessment MDS dated January 1, 2025, incorrectly indicated that the resident had developed a stage 2 pressure ulcer while residing in the facility. However, upon review of the clinical records and interviews with staff and the resident, it was determined that this was a data entry error. The resident's clinical records showed no orders for treatment of a stage 2 pressure ulcer, and interviews confirmed that the resident did not have such an ulcer at the time of the MDS assessment. The resident's care plan, last revised in November 2024, documented a risk for skin injury due to immobility, paraplegia, a history of stage 4 wounds, and tendon release surgery. Despite this, the resident only had a skin tear on the inner thigh, which was being treated and was improving. Interviews with the resident and staff confirmed the absence of a pressure ulcer, and the MDS Coordinator acknowledged the data entry error. This error led to the inaccurate documentation of the resident's condition in the MDS assessment.
Failure to Develop Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident regarding oxygen use. The resident, who was admitted with diagnoses of acute on chronic systolic heart failure and chronic obstructive pulmonary disease, was observed using supplementary oxygen in their room. The clinical records indicated an order for continuous oxygen via nasal cannula at 2 liters per minute. However, the current care plan did not include any person-centered interventions addressing the resident's oxygen needs. The Director of Nursing confirmed the absence of a comprehensive care plan for the resident's oxygen use.
Failure to Monitor Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor a fluid restriction ordered by a physician for a resident diagnosed with congestive heart failure and dementia. The resident was admitted with a physician's order for a 2-liter per day fluid restriction. However, a review of the clinical record showed no evidence that nursing staff monitored this fluid restriction. An interview with the Director of Nursing confirmed that the nursing staff did not monitor the fluid restriction as ordered. Additionally, the Director of Nursing revealed that upon review, the resident should not have been on a fluid restriction from admission, and the restriction was subsequently removed.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor a resident with significant weight loss. Resident 104, diagnosed with protein-calorie malnutrition and adult failure to thrive, experienced a 6 percent weight loss over 14 days, dropping from 136.6 pounds to 128.4 pounds. The clinical record did not show evidence that the resident's physician was notified of this significant weight loss. Additionally, there was no documentation of a re-weight being obtained to verify the accuracy of the weight loss. An interview with Licensed Employee E3 confirmed that a re-weight should have been conducted and that the physician was not informed of the weight loss, which was not addressed.
Failure to Adhere to Fluid Restrictions for Dialysis Resident
Penalty
Summary
The facility failed to adhere to fluid restrictions for a resident with end-stage renal disease (ESRD) and dementia, leading to a deficiency in providing appropriate dialysis care. The resident had a physician's order for a daily fluid restriction of 1500 ml, distributed across different shifts and dietary services. However, the resident's fluid intake exceeded this limit on multiple occasions, as documented in the Fluid Task sheet. Specific instances of excess fluid intake were recorded on several dates, with amounts ranging from 180 ml to 780 ml over the prescribed limit. The Director of Nursing confirmed these findings during an interview.
Failure to Maintain Privacy and Confidentiality of Residents' Information
Penalty
Summary
The facility failed to provide privacy and confidentiality of residents' personal information on two of four nursing units (South and East). On April 2, 2024, at approximately 10:00 a.m., a computer on the medication cart in the East unit was left unattended with a resident's physician orders displayed, with several residents and staff nearby. Similar observations were made on April 3, 2024, at approximately 8:00 a.m. on the South unit, and on April 5, 2024, at approximately 8:30 a.m. on the East unit, where computers on medication carts were left unattended with residents' physician orders displayed. The Director of Nursing confirmed these findings on April 5, 2024, at 10:20 a.m.
Failure to Complete Discharge Summary on Planned Discharge Day
Penalty
Summary
The facility failed to complete a discharge summary on the day of a planned discharge for one of three residents reviewed. Resident 109 was admitted to the facility and discharged to home on March 23, 2024. However, a review of Resident 109's clinical record revealed that the discharge summary was not completed on the day of the planned discharge. This information was conveyed to the Nursing Home Administrator on April 5, 2024, at 11:00 a.m.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to consistently implement and maintain infection control practices for a resident requiring contact precautions. Specifically, Resident 90, who had a urinary analysis positive for Extended Spectrum Beta-Lactamase E. coli, was not properly managed according to the facility's Transmission-Based Precautions and Isolation Policy. Observations revealed that the contact precaution sign was placed face down outside the resident's room, and nursing staff were seen performing incontinence care with only gloves on, without wearing gowns as required. Additionally, staff were observed exiting the resident's room with soiled bed linens without wearing gowns and entering the room without washing their hands or donning PPE. One staff member, an LPN, was unaware that Resident 90 was on contact precautions or that the resident's UA had returned positive for ESBL E. coli. Interviews with staff confirmed the lack of adherence to the facility's infection control policies. The Infection Preventionist acknowledged that Resident 90 was on contact precautions and that all staff needed to follow the facility's transmission-based precautions and isolation policy. The failure to properly implement these precautions was confirmed by the Infection Preventionist, highlighting a significant lapse in infection control practices within the facility.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
