Twin Pines Health Care Center

In the surveyor’s words

From the most serious findings on record at Twin Pines Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 19, 2022

  Intakes: PA 238, PA 236 Based on observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure the hot beverage policy included parameters identifying safe beverage temperatures for hot liquids resulting in actual harm to one resident who sustained [CONDITION(S)] on the right thigh/hip. This resulted in an Immediate Jeopardy, past non-compliance situation when it was determined that the policy failed to identify hot beverage temperature parameters which had the potential to cause the residents discomfort or pain, to jeopardize the health and safety of 25 residents of 108 total skilled nursing residents. […]

• Actual harm, isolatedF580Jun 22, 2026

  Based on review of the facility's policy, clinical records, hospital records, and interviews with staff, nurse practitioner, resident, and family, it was determined the facility failed to timely notify and report accurate information of a resident's change in condition to the physician for one of two residents reviewed (Resident 1). This failure resulted in actual harm of the resident when they were hospitalized , requiring intubation, mechanical ventilation, and ICU (Intensive Care Unit) admission for monitoring. Findings Include: Review of the facility's policy titled Resident Change in Condition Policy, last reviewed on June 2, 2025, revealed The licensed nurse will recognize and intervene in the event of a change in resident condition. […]

• Actual harm, isolatedF600Feb 27, 2023

  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). […]

• Actual harm, isolatedF689Feb 27, 2023

  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). […]

• Actual harm, isolatedF600Apr 8, 2021

  Based on a review of the facility's policy, facility documentation review, clinical record review, resident and staff interviews, it was determined that the facility failed to ensure that one of eight residents reviewed (Resident #1) was free of neglect during care which resulted in actual harm by sustaining a right distal femoral (the area of the leg just above the knee joint space) fracture due to a fall from the bed. Findings include: A review of the facility's policy titled, Abuse, Neglect, and Exploitation, with a revision date of May 2019, revealed that neglect is the failure of the facility, its employees, or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or mental illness. […]