TWIN PINES HEALTH CARE CENTER

315 EAST LONDON GROVE ROAD, WEST GROVE, PA 19390 (610) 869-2456
For profit - Corporation 119 Beds SABER HEALTHCARE GROUP Data: November 2025
Trust Grade
53/100
#371 of 653 in PA
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Last Inspection: March 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Twin Pines Health Care Center has a Trust Grade of C, indicating it is average and in the middle of the pack among nursing homes. It ranks #371 out of 653 facilities in Pennsylvania, placing it in the bottom half, and #17 out of 20 in Chester County, meaning only a few local options are better. The facility's performance is worsening, with issues increasing from 3 in 2024 to 8 in 2025. Staffing is considered a strength, with a 39% turnover rate, which is below the state average of 46%, but the facility has concerning RN coverage, being lower than 93% of Pennsylvania facilities. Specific incidents include a resident being transferred by one staff member instead of the required two, posing a fall risk, as well as multiple instances where residents' confidential medical information was left exposed on unattended computers. Overall, while there are strengths in staffing stability, the facility's increasing issues and privacy concerns are significant weaknesses families should consider.

Trust Score
C
53/100
In Pennsylvania
#371/653
Bottom 44%
Safety Record
Moderate
Needs review
Inspections
Getting Worse
3 → 8 violations
Staff Stability
○ Average
39% turnover. Near Pennsylvania's 48% average. Typical for the industry.
Penalties
⚠ Watch
$15,593 in fines. Higher than 95% of Pennsylvania facilities. Major compliance failures.
Skilled Nurses
⚠ Watch
Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
13 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 8 issues

The Good

  • 4-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (39%)

    9 points below Pennsylvania average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

3-Star Overall Rating

Near Pennsylvania average (3.0)

Meets federal standards, typical of most facilities

Staff Turnover: 39%

Near Pennsylvania avg (46%)

Typical for the industry

Federal Fines: $15,593

Below median ($33,413)

Minor penalties assessed

Chain: SABER HEALTHCARE GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 13 deficiencies on record

2 actual harm
Mar 2025 8 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 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 no...

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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
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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. (Res...

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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) 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
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**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 comp...

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**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
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

**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 inst...

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**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
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**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...

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**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). 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
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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). Findings include: Revi...

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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). 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
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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. (...

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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). 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
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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). Fi...

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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
Apr 2024 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, it was determined the facility failed to complete discharge summary on the day of planned dis...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, it was determined the facility failed to complete discharge summary on the day of planned discharge for one of three residents reviewed (Resident 109). Findings include: Review of Resident 109's clinical record revealed Resident 109 was admitted to the facility on [DATE], and was discharged to home on March 23, 2024. Review of Resident 109's clinical record failed to reveal a discharge summary completed on March 23, 2024, the day of a planned discharge. The above information was conveyed to the Nursing Home Administrator on April 5, 2024, at 11:00 a.m. 28 Pa. Code 211.5(f) Clinical Records
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on a comprehensive review of clinical records, observations, and interviews with residents and staff, it was determined that the facility failed to consistently implement and maintain infection ...

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Based on a comprehensive review of clinical records, observations, and interviews with residents and staff, it was determined that the facility failed to consistently implement and maintain infection control practices, thereby risking the potential spread of infection for one resident requiring contact precautions (a method to prevent the transmission of infectious agents spread by direct or indirect contact with the patient or the patient's environment) out of 32 residents sampled (Resident 90). Findings include: Review of the facility's policy Transmission-Based Precautions and Isolation Policy with a revision date of March 3, 2024, states that Contact precautions also apply where the presence of excessive wound drainage, urine, or fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Personal Protective Equipment (PPE) recommended includes gloves and gowns. Review of the CONTACT PRECAUTIONS sign reveals instructions for all personnel to clean their hands before entering and leaving the room, and for providers and staff to don gloves and gowns before room entry and discard them before room exit. A review of Resident 90's clinical medical record revealed a progress note dated March 28, 2024 at 1:01 p.m. stating Resident 90's urinary analysis (UA) came back positive for Extended Spectrum Beta-Lactamase e-coli (ESBL, are enzymes produced by certain bacteria, including Escherichia coli that make bacteria resistant to certain antibiotic medicines) (Escherichia-coli, is a group of bacteria that can cause infections in one's gut, urinary tract and other parts of your body). During a tour of nursing unit East on April 2, 2024, at 10:31 a.m., it was observed that the PPE station, including gloves, gowns, and face shields, was available, but the contact precaution sign was placed face down on top of the container outside Resident 90's room. Additional observations conducted on nursing unit East on April 2, 2024, at 10:33 a.m. revealed three nursing staff performing incontinence care (helping an individual with any type of urinary or bowel leakage to maintain their health, and wellbeing) on Resident 90 with only gloves on. Observations conducted on April 3, 2024, at 9:36 a.m., witnessed a nursing staff exiting Resident 90's room holding soiled bed linens without wearing a gown. Additional observations of Resident 90's room on April 3, 2024, at 9:39 a.m. observed two nursing staff entering Resident 90's room without washing their hands or dawning PPE. At 9:35 a.m. licensed practical nurse (LPN) licensed employee (E4) exited Resident 90's room without washing her hands. Interview conducted with licensed employee E4 on April 3, 2024, at 9:35 a.m. revealed E4 was unaware resident 90 was on contact precautions or that Resident 90's UA returned positive for ESBL E-coli. Interview conducted with Infection Preventionist (IP) licensed employee (E3) on April 3, 2024, at 1:18 p.m. confirmed Resident 90 is on contact precaution and that all staff need adhere to the facility's transmission-based precautions and isolation policy. The above information was confirmed by licensed employee E3 on April 3, 2024, at 1:24 p.m. 28 Pa. Code 211.10 (a)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(2)(5) Nursing Services.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

Based on observation, it was determined that the facility failed to provide privacy and confidentiality of residents ' personal information on two of four nursing units (South and East). Findings incl...

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Based on observation, it was determined that the facility failed to provide privacy and confidentiality of residents ' personal information on two of four nursing units (South and East). Findings include: Observation on the East unit on April 2, 2024, at approximately 10:00 a.m. revealed the computer on the medication cart was left unattended with Resident 85's physician orders displayed. Several residents and other staff were noted nearby the medication cart. Observation on the South unit on April 3, 2024, at approximately 8:00 a.m. revealed the computer on the medication cart was left unattended with Resident 59's physician orders displayed. Several residents and other staff were noted nearby the medication cart. Observation on the East unit on April 5, 2024, at approximately 8:30 a.m. revealed the computer on the medication cart was left unattended with Resident 29's physician orders displayed. Several residents and other staff were noted nearby the medication cart. Interview with the Director of Nursing on April 5, 2024, at 10:20 a.m. confirmed the above findings. 28 Pa. Code: 201.18 (e)(1) Management 28 Pa. Code: 201.29 (j) Resident rights 28 Pa. Code: 211.5 (f) Clinical records
Feb 2023 2 deficiencies 2 Harm
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview it was determined that the facility failed to ensure that a resident was free from...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview it was determined that the facility failed to ensure that a resident was free from neglect by not providing the two person assistance needed during incontinence care which resulted in actual harm of a left foot fracture for one of two residents reviewed (Resident R2). This was identified as a past non compliance situation. Findings include: Review of Resident R2's clinical record revealed diagnoses including but not limited to the following: Abnormalities of Gait; Muscle Weakness; Obesity (excessive amount of body fat); and Osteoarthritis (common form of arthritis, affects the joints, causing pain, stiffness and reduced movement). Review of Resident R2's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated October 19, 2022 revealed in Section G (Functional Status) subsection A. Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) was rated 3/3; indicating resident needed extensive assistance of two or more staff/persons for physical assist. Review of Resident R2's [NAME] (document used to indicate how individual resident care should be performed) revealed under category of Mobility; Transfer with two assist and hoyer lift. Review of Resident R2's care plans revealed a goal of Risk for Self Care deficient r/t [related to] immobility. The care plan included intervention of Assist of 2 with ADL [Activities of Daily Living]. Staff assist of 2 for mobility, upper and lower body ADLs, toileting/incontinence care, bath/showers. Further review of Resident R2's care plans revealed a focus goal of Resident fall/at risk for falls characterized by impaired mobility, hx [history] of anxiety with moving around, obesity, and decline in health. Additional review of this focus goal revealed an intervention of re-educate and reinforce adherence to 2 person assist for bed mobility initiated December 13, 2022. Review of Resident R2's clinical record revealed an Incident Note dated December 13, 2022 (22:21 AKA 10:21 p.m.) which revealed, Called in by CNA [certified nurse assistant] to assess resident post fall. Upon arrival to room, resident observed on floor on [his/her] stomach, AAOx3, verbal, c/o feeling dizzy, unable to roll over to sides and c/o headache and B/L knee pain. Resident noted with a laceration to the leftside of head and also to the right Forearm. VS- 207/127, 91. Resident had a witnessed fall and did hit her head on the dresser at the time of fall. On call CRNP (Certified Registered Nurse Practitioner) called and made aware of clinical situation, new order received to transfer resident to the ER (Emergency Room) for further evaluation. 911 called, team arrived, and resident transferred at 10pm to [local] Emergency. Further review of Resident R2's clinical record revealed a Head to Toe Evaluation Progress note dated December 13, 2022 (23:31 aka 11:31 p.m.) indicating, Resident had a witnessed fall and did hit her head on the dresser at the time of fall. Upon arrival to room, resident observed on floor on her stomach, verbally responsive, c/o feeling dizzy, unable to roll over to sides and c/o [complaint/of] headache and B/L [bilateral] knee pain. Resident noted with a laceration to the left-side of head and also to the right Forearm. The same progress note further revealed, Evidence of pain noted pain to head Pain is throbbing Pain level is 7 out of 10. The pain is constant. Additional review of Resident R2's clinical record revealed a Nursing progress note dated December 14, 2022 at 06:54 (a.m.) which indicated, (RN) from [hospital emergency department] called back to report that resident does have a left foot fracture and got a splint and need to follow up with orthopedics. Review of X-ray results dated December 14, 2022 (00:52:19 a.m.) revealed under category of Impressions a subcategory of history indicating fell out of bed. Further review under subcategory Findings revealed Acute nondisplaced intra-articular fracture proximal end first metatarsal. Review of facility documents of fall investigation including Witness Statement, Incident/Accident or Injury of Unknown Origin by non licensed Employee E3 revealed telephone interview statement of I was doing my last rounds. I had cleaned [resident] all up, I had her all cleaned up, I was on the other side of the bed and I was getting ready to roll her back, it seems like she was moving too fast, she had started rocking and I started to head towards the other side of the bed and when I rounded toward the foot of the bed she fell. Further review of witness statement revealed after asked question, are you aware that [he/she's] a two person with bed mobility? Employee E3 responded, I have always had two people in there with me and yes, I am aware that [he/she]'s a two person. Additional review of witness statement/telephone interview document revealed Employee E3 was questioned of When you went in the room to check on [him/her] who did you ask to come in with you? with Employee E3 responding, I didn't ask anybody. Interview on February 24, 2023 at approximately 8:00 p.m. with Interim Director of Nursing, confirmed the resident was a two person assist needed for bed mobility and nurse aide provided incontinence care alone instead of using second aide. The facility failed to ensure the incontinence care for Resident R2 was conducted with two staff members which resulted in neglect and actual harm of a fracture to the left foot. The facility submitted a corrective action plan that included a full house sweep to determine any other residents affected by deficient practice including interviews with residents and observations of staff's incontinence care. Care plans were reviewed for accuracy of incontinence care needs. Each nurse and aide received education regarding following care plans for assistance needed during care. Random audits were completed to ensure incontinence care was completed safely and appropriately. Interviews conducted with licensed staff member Employee E2, Employee E4, non licensed staff member Employee E5, and Employee E6 revealed understanding of abuse/neglect definitions as well as safety/supervision during incontinence care and following [NAME] and/or care plan regarding bed mobility needs of residents. Review of facility documentation showed that the corrective action had been fully implemented and completed by February 8, 2023. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 483.25 Free of Accidents/Hazards/Supervision Previously cited 04/19/22 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/03/22 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 6/03/22 28 Pa. Code 211.12(c) Nursing services Previously cited 6/03/22; 4/19/22 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 4/19/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/03/22; 4/19/22
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview it was determined that the facility failed to ensure Resident R2 was free from acc...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview it was determined that the facility failed to ensure Resident R2 was free from accidents and hazards and appropriately supervised during incontinence care which resulted in the actual harm of a left foot fracture for one of two residents reviewed. This was identified as a past non compliance situation. Findings include: Review of Resident R2's clinical record revealed diagnoses including but not limited to the following: Abnormalities of Gait; Muscle Weakness; Obesity (excessive amount of body fat); and Osteoarthritis (common form of arthritis, affects the joints, causing pain, stiffness and reduced movement). Review of Resident R2's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated October 19, 2022 revealed in Section G (Functional Status) subsection A. Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) was rated 3/3; indicating resident needed extensive assistance of two or more staff/persons for physical assist. Review of Resident R2's [NAME] (document used to indicate how individual resident care should be performed) revealed under category of Mobility; Transfer with two assist and hoyer lift. Review of Resident R2's care plans revealed a goal of Risk for Self Care deficient r/t [related to] immobility. The care plan included intervention of Assist of 2 with ADL [Activities of Daily Living]. Staff assist of 2 for mobility, upper and lower body ADLs, toileting/incontinence care, bath/showers. Further review of Resident R2's care plans revealed a focus goal of Resident fall/at risk for falls characterized by impaired mobility, hx [history] of anxiety with moving around, obesity, and decline in health. Additional review of this focus goal revealed an intervention of re-educate and reinforce adherence to 2person assist for bed mobility initiated December 13, 2022. Review of Resident R2's clinical record revealed an Incident Note dated December 13, 2022 (22:21 AKA 10:21 p.m.) which revealed, Called in by CNA [certified nurse assistant] to assess resident post fall. Upon arrival to room, resident observed on floor on [his/her] stomach, AAOx3, verbal, c/o feeling dizzy, unable to roll over to sides and c/o headache and B/L knee pain. Resident noted with a laceration to the leftside of head and also to the right Forearm. VS- 207/127, 91. Resident had a witnessed fall and did hit her head on the dresser at the time of fall. On call CRNP (Certified Registered Nurse Practitioner) called and made aware of clinical situation, new order received to transfer resident to the ER (Emergency Room) for further evaluation. 911 called, team arrived, and resident transferred at 10pm to [local] Emergency. Further review of Resident R2's clinical record revealed a Head to Toe Evaluation Progress note dated December 13, 2022 (23:31 aka 11:31 p.m.) indicating, Resident had a witnessed fall and did hit her head on the dresser at the time of fall. Upon arrival to room, resident observed on floor on her stomach, verbally responsive, c/o feeling dizzy, unable to roll over to sides and c/o [complaint/of] headache and B/L [bilateral] knee pain. Resident noted with a laceration to the left-side of head and also to the right Forearm. The same progress note further revealed, Evidence of pain noted pain to head Pain is throbbing Pain level is 7 out of 10. The pain is constant. Additional review of Resident R2's clinical record revealed a Nursing progress note dated December 14, 2022 at 06:54 (a.m.) which indicated, (RN) from [hospital emergency department] called back to report that resident does have a left foot fracture and got a splint and need to follow up with orthopedics. Review of x-ray results dated December 14, 2022 (00:52:19 a.m.) revealed under category of Impressions a subcategory of history indicating fell out of bed. Further review under subcategory Findings revealed Acute nondisplaced intra-articular fracture proximal end first metatarsal. Review of facility documents of fall investigation including Witness Statement, Incident/Accident or Injury of Unknown Origin by non licensed Employee E3 revealed telephone interview statement of I was doing my last rounds. I had cleaned [resident] all up, I had her all cleaned up, I was on the other side of the bed and I was getting ready to roll her back, it seems like she was moving too fast, she had started rocking and I started to head towards the other side of the bed and when I rounded toward the foot of the bed she fell. Further review of witness statement revealed after asked question, are you aware that [he/she's a two person with bed mobility? Employee E3 responded, I have always had two people in there with me and yes, I am aware that [he/she]'s a two person. Additional review of witness statement/telephone interview document revealed Employee E3 was questioned of When you went in the room to check on [him/her] who did you ask to come in with you? with Employee E3 responding, I didn't ask anybody. Interview on February 24, 2023 at approximately 8:00 p.m. with Interim Director of Nursing, confirmed the resident was a two person assist needed for bed mobility and nurse aide provided incontinence care alone instead of using second aide. The facility failed to ensure Resident R2 was free from accidents and supervised during care which resulted in actual harm of fracture to foot. The facility submitted a corrective action plan that included a full house sweep to determine any other residents affected by deficient practice including interviews with residents and observations of staff's incontinence care. Care plans were reviewed for accuracy of incontinence care needs. Each nurse and aide received education regarding following care plans for assistance needed during care. Random audits were completed to ensure incontinence care was completed safely and appropriately. Interviews conducted with licensed staff member Employee E2, Employee E4, non licensed staff member Employee E5, and Employee E6 revealed understanding of abuse/neglect definitions as well as safety/supervision during incontinence care and following [NAME] and/or care plan regarding bed mobility needs of residents. Review of facility documentation showed that the corrective action had been fully implemented and completed by February 8, 2023. 483.25 Free of Accidents/Hazards/Supervision Previously cited 04/19/22 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/03/22 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 6/03/22 28 Pa. Code 211.12(c) Nursing services Previously cited 6/03/22; 4/19/22 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 4/19/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/03/22; 4/19/22
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • 39% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
  • • 13 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
  • • $15,593 in fines. Above average for Pennsylvania. Some compliance problems on record.
  • • Grade C (53/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 53/100. Visit in person and ask pointed questions.

About This Facility

What is Twin Pines Health's CMS Rating?

CMS assigns TWIN PINES HEALTH CARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Twin Pines Health Staffed?

CMS rates TWIN PINES HEALTH CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 39%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Twin Pines Health?

State health inspectors documented 13 deficiencies at TWIN PINES HEALTH CARE CENTER during 2023 to 2025. These included: 2 that caused actual resident harm and 11 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Twin Pines Health?

TWIN PINES HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SABER HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 119 certified beds and approximately 112 residents (about 94% occupancy), it is a mid-sized facility located in WEST GROVE, Pennsylvania.

How Does Twin Pines Health Compare to Other Pennsylvania Nursing Homes?

Compared to the 100 nursing homes in Pennsylvania, TWIN PINES HEALTH CARE CENTER's overall rating (3 stars) matches the state average, staff turnover (39%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Twin Pines Health?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Twin Pines Health Safe?

Based on CMS inspection data, TWIN PINES HEALTH CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Twin Pines Health Stick Around?

TWIN PINES HEALTH CARE CENTER has a staff turnover rate of 39%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Twin Pines Health Ever Fined?

TWIN PINES HEALTH CARE CENTER has been fined $15,593 across 2 penalty actions. This is below the Pennsylvania average of $33,235. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Twin Pines Health on Any Federal Watch List?

TWIN PINES HEALTH CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

TWIN PINES HEALTH CARE CENTER

315 EAST LONDON GROVE ROAD, WEST GROVE, PA 19390 | (610) 869-2456

C
Trust Grade (53/100)
3.0
CMS Rating
13
Deficiencies

Strengths

  • 4-star quality

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025