GREENSBURG, PA- TWIN LAKES REHABILITATION AND HEALTHCARE CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Based on review of the Resident Assessment Instrument User’s Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required timeframe for four of 66 residents reviewed (Residents 26, 60, 93, 96).

Assure that each resident’s assessment is updated at least once every 3 months.

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for two of 66 residents reviewed (Residents 23, 60).

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for three of 66 residents reviewed (Resident 7, 64, 97) and failed to ensure that physician orders were followed for one of 66 residents reviewed (Resident 90).

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation and failed to administer treatments per physician’s orders for one of 66 residents reviewed (Resident 74).

Provide enough food/fluids to maintain a resident’s health.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents maintained acceptable parameters of nutritional status by failing to ensure timely notification of the physician for one of 66 residents reviewed (Resident 65).

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Based on review of clinical record reviews and facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents who were receiving tube feedings received appropriate treatment and services to prevent complications for one of 66 residents reviewed (Resident 51).

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 66 residents reviewed (Resident 64).

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that dietary staff wore hair coverings that completely covered their facial hair during food handling and failed to store and prepare food in accordance with professional standards for food service safety by not dating opened food items and not storing food under sanitary conditions.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Based on review of the facility’s plans of correction for previous surveys, and the results of the current survey, it was determined that the facility’s Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Provide and implement an infection prevention and control program.

Based on review of policies and clinical records, as well as observations and staff interviews, it was
determined that the facility failed to ensure that proper infection control practices were followed while providing medications for one of 66 residents reviewed (Resident 79), failed to ensure that proper infection control practices were followed for urinary catheter care for one of 66 residents reviewed (Resident 109), and failed to report COVID positive residents and staff to the Department of Health.