Twin Lakes Community

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 21, 2022

  Based on observations, staff interviews, and record review, the facility failed to place a call bell within the reach of a dependent resident to call for assistance. Resident #88 was unable to call for assistance with toileting when her call bell was out of reach and attempted to get the call bell and fell . Resident #88 sustained injuries from the fall that included closed left femur fracture and hospitalized for four days. The facility also failed to transfer a resident with the required level of staff assistance for Resident #67. This deficient practice was for 2 of 2 residents reviewed for supervision to prevent accidents (Resident #88 and #67). The findings included: 1. […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2022

  Based on observation and staff interviews the facility failed to ensure foods were not opened to air in 1 of 1 walk-in dry storage closet and in 1 of 5 satellite kitchens ([NAME] unit) and failed to label, date, and discard expired foods in 4 of 5 nourishment refrigerators (Outer Banks, [NAME], Blue Ridge, and Highlands units). The facility also failed to ensure pork was stored to prevent cross-contamination in 1 of 1 walk-in refrigerator. These practices had the potential to affect food served to residents. The findings include: 1. An initial tour of the main kitchen on [DATE] at 11:30 AM revealed the walk-in dry storage closet to have a bag of chocolate chips unsealed and open to air. During the observation, the Chef Team Leader revealed the chocolate chips should have been sealed. 2. […]

• No harm, potential for more than minimal, patternF638Mar 19, 2026

  Based on record review and staff interview the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, the last day of the look-back period) for 10 of 24 residents reviewed for MDS assessments (Residents #3, #9, #37, #50, #99, #49, #16, #57, #77 and #83).The findings included:a. Resident #3 was admitted to the facility on [DATE].Resident #3's quarterly MDS assessment with an ARD of 2/4/26 indicated it was in progress and was not completed. b. Resident #9 was admitted to the facility on [DATE].Review of Resident #9's quarterly MDS assessment with an ARD of 1/24/26 indicated it was in progress and was not completed. c. […]

• No harm, potential for more than minimal, patternF602Aug 7, 2024

  Based on record review and interviews with residents, staff, and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 1 of 4 resident (Resident #2) reviewed for misappropriation of residents' property. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised in August 2024, revealed in part the facility would ensure all residents to remain free from abuse or misappropriation of their property. Resident #2 was admitted to the facility on [DATE] and discharged home on 4/30/24. […]

• No harm, potential for more than minimal, patternF603Aug 7, 2024

  Based on record review and interviews with residents, staff, and physician, the facility failed to protect residents' rights to be free from involuntary seclusion for 1 of 3 resident (Resident #1) reviewed for abuse. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised in August 2024, revealed in part the facility would ensure all residents to remain free from involuntary seclusion. Resident #1 was admitted to the facility on [DATE]. The diagnoses included vascular dementia, cerebral vascular accident, restless leg syndrome and atrial fibrillation. The significant change Minimum Data Set(MDS) dated [DATE] indicated Resident #1's cognition was severely impaired. Resident's #1's mode of transportation was the wheelchair. […]