Twin Pines Health Care Center
TWIN PINES HEALTH CARE CENTER in WEST GROVE, PA — inspection on April 30, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reviewed, and revised by a team of health professionals.
facility failed to ensure care plans were updated for appropriate wheelchair positioning for one of
Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated August 7, 2025, revealed resident had a diagnosis of Alzheimer's' Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Seizure disorders (A chronic neurological condition characterized by recurrent seizures caused by abnormal electrical activity in the brain), and Contracture-knee (A permanent, stiffening of muscles, tendons, ligaments or skin, causing restriction in joint movement).
The same MDS revealed that residents' cognition was severely impaired and dependent on all ADL's (activities of daily living).A review of Resident 9's progress notes dated September 17, 2025, at 11:01 a.m., revealed Resident observe laying on the floor in the common living room area.
Resident was laying prone in front of (their) wheelchair when staff observed (them).
Resident was assessed for injury, noted with hematoma (Localized collection of clotted blood outside blood vessel) to R (right) frontal area of forehead, abrasion noted on the area with minimal bleeding, pressure dressing applied.An observation conducted on April 29, 2026, at 9:45 a.m., revealed Resident 9 was lying in bed with eyes closed, both legs and arms were flexed.
Further observations revealed licensed Employee E6 approached and spoke to the resident, raised the head of the bed and administered the resident's medications.
The resident did not move during the entire observation. A high back chair reclined at 45 degrees with a footrest and board was observed in the resident's room.An interview conducted with Employee E6 on April 29, 2026, at 9:50 a.m., revealed that they were the residents' full-time nurses.
Employee E6 reported Resident 9 was unable to reposition self but had jerking movements episodes.
Employee E6 reported that they assessed Resident 9 after the fall on September 17, 2026.
Employee E6 confirmed that the high back chair in the resident's room was the same chair in use when they fell.
Employee E6 further stated It's reclined now (pointing at the chair in the room) but it was straight up during the fall because they just finish eating.
Employee 6 further stated I don't remember the footrest being there.A review of Resident 9's Rehabilitation Services Screening dated May 5, 2025, revealed Recommend semi-reclining wheelchair for OOB (out of bed) slightly reclined high back and position trunk in midline for comfort.
Feet may rest on leg rest calf pads due to reduced knee extension ROM (range of motion).A review of Resident 9's active care plan revealed rehab recommendations for appropriate wheelchair positioning were not added into the residents' plan of care.An interview with the Director of Nursing on April 30, 2026, at 11:00 a.m., confirmed that rehab recommendations for appropriate wheelchair positioning were not reflected in the resident's care plan.
The facility failed to ensure Resident 9 care plan was revised to reflect appropriate wheelchair positioning. 28 Pa.
Code 211.12(c)(d)(1)(5) Nursing services
396114 04/30/2026
Twin Pines Health Care Center 315 East London Grove Road West Grove, PA 19390
March 2, 2026, March 3, 2026 and March 4, 2026, March 5, 2026, March 6, 2026, and March 7, 2026, the
conducted on April 30, 2026, at 1:30 p.m., confirmed that resident 27 and 83's physician was not
failed to ensure the physician was notified of Resident 27 and 83's significant weight loss and further interventions were put in place to prevent further weight loss timely.28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services
The facility failed to ensure that food stored in the walk-in freezer in the main kitchen was properly stored to prevent contamination and ensure safe storage in accordance with professional standards for food service safety. 28 Pa.
Code 211.6(f) Dietary services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
396114 04/30/2026
Twin Pines Health Care Center 315 East London Grove Road West Grove, PA 19390
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.