Twin Lakes

In the surveyor’s words

From the most serious findings on record at Twin Lakes, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF730May 28, 2026

  Based on review of personnel files, staff interview, and review of the facility policy, the facility failed to ensure Certified Nursing Assistants (CNAs) received 90-day performance evaluations. This had the potential to affect all of the residents. The facility census was 34 residents. Findings include: Review of the personnel file for CNA #500 revealed a hire date of 08/18/25 with no 90-day evaluation. Review of the personnel file for CNA #505 revealed a hire date of 11/24/25 with no 90-day evaluation. Interview on 05/27/26 at 4:00 P.M. with Regional Human Resource Manager #175 verified CNAs #500 and #505 did not receive 90-day evaluations. […]

• No harm, potential for more than minimal, widespreadF812May 28, 2026

  Based on observation, staff interview, and review of the facility policy, the facility failed to properly store foods in a safe and sanitary manner. This had the potential to affect all of the residents residing in the facility. The facility census was 34 residents. Findings include: Observation on 05/26/26 at 9:10 A.M. of main kitchen walk in refrigerator with Dietary Manager (DM) #201 revealed it contained a pan with pre-cooked undated meatloaf and an opened undated box of sausage patties. Interview on 05/26/26 at 9:10 A.M. with DM #301 confirmed the meatloaf and sausage patties were undated and should be discarded. Observation on 05/26/26 at 9:17 A.M. […]

• No harm, potential for more than minimal, isolatedF644May 28, 2026

  Based on medical record review and staff interview, the facility failed to ensure a preadmission screening resident review (PASARR) screenings were completed accurately. This affected one (Resident #2) of three residents reviewed for PASARR screening. The facility census was 34 residents.Findings include: Review of the medical record revealed for Resident #2 revealed an admission date of 12/21/22 with diagnoses including cerebral infarction, vascular dementia, diabetes mellitus type two, atrial fibrillation, and hypertension. […]

• No harm, potential for more than minimal, isolatedF689May 28, 2026

  Based on observation, staff interview, and record review, the facility failed to properly store potentially hazardous chemicals in two of two satellite kitchens in the skilled nursing unit. This had the potential to affect three facility-identified cognitively impaired and independently mobile residents (Residents #3, #12, and #24) of 34 residents residing in the facility. The facility census was 34 residents. Findings include: 1. Observation on 05/26/26 at 9:49 A.M. of the community kitchenette on [NAME] Court nursing unit revealed there was a spray bottle of Kontrol Morning Fresh in an open cabinet under the sink. The label on the spray bottle indicated the contents were flammable and could cause skin irritation. Interview on 05/26/26 at 9:50 A.M. […]

• No harm, potential for more than minimal, isolatedF761May 28, 2026

  Based on medical record review, observation, staff interview, review of pharmacy guidelines, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected two (Residents #49 and #2) of 29 residents with medications stored in the [NAME] Nursing Unit-A and [NAME] Nursing Unit medication carts. The facility census was 34 residents. Findings include: 1. Review of the medical record for Resident #49 revealed an admission date of [DATE] with a diagnosis of diabetes mellitus type two. Review of the physician's orders for Resident #49 revealed an order dated [DATE] for Humalog insulin four units subcutaneously with breakfast and six units with dinner. […]