Twinbrook Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Twinbrook Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Jul 15, 2022

  Based on observations, review of facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for two of eight residents reviewed (Residents R1 and R5). Findings include: Review of the original facility policy entitled COVID-19 Pandemic Policy dated 6/3/22, did not address practices to include not cohorting COVID-19 positive and negative residents together in the same room. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2025

  Based on observations, review of dishwashing machine manufacturer's instructions, and staff interviews, it was determined that the facility failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety for the kitchen dishwasher. Findings include: Review of manufacturer's instructions for the facility dishwashing machine revealed that the hot water sanitizing mode minimum wash temperature and recommended wash temperature was 150-165 degrees Farenheit (F). The rinse temperature was 180-194 degrees F. Review of the Dishwashing/Warewashing machine temperature log sheet revealed that the minimum temperature requirements for the wash cycle was: Wash 150 degrees F and the Rinse 180 degrees F. […]

• No harm, potential for more than minimal, widespreadF812Jul 15, 2022

  Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was served in a sanitary manner. Findings include: Review of facility policy entitled Food Service Hair Net Requirements with a policy review date of 6/3/22, indicated Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed to effectively keep hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-serve and single-use articles. Observation of the kitchen tray line food service on 7/13/22, from 11:45 a.m. through 12:00 p.m. […]

• No harm, potential for more than minimal, patternF550Aug 12, 2026

  Based on review of facility policy and documentation, and resident interviews, it was determined that the facility failed to treat each resident with respect and dignity in a homelike environment that promotes maintenance or enhancement of his or her quality of life for seven of 18 residents sampled (Residents R2, R4-R9). Findings include:A Facility Policy entitled Homelike Environment dated 2/09/26, indicated that staff would provide person-centered care that emphasizes the residents' comfort and personal needs and preferences, and maintain comfortable sound levels.Review of three months of grievances revealed that on 5/11/26, it was reported that the Nurse Aids have been arguing with the resident and treating him/her poorly. […]

• No harm, potential for more than minimal, patternF558Aug 12, 2026

  Based on observations, review of clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that resident call bells were within reach for seven of 18 residents reviewed (Residents R1, R12, R13, R14, R15, R16, R17, and R18).Findings include:The facility could not provide a policy regarding residents' access to call bells.Observations 8/12/26, between 10:18 a.m. and 10:30 a.m. revealed the following: Resident R18 sitting upright in bed and his/her call bell lying across the nightstand and out of reach; Resident R13 sitting upright in bed and his/her call bell lying on the floor behind the bed and out of reach; Resident R1 sitting upright in bed and his/her call bell lying on the floor next to the bed and out of reach; Resident R14 sitting in… […]