Twin Lakes Extended Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 14, 2023

  Based on interview and record review the facility failed to protect the resident's right to be free from sexual abuse by another resident by failing to supervise a resident (R1) with known sexual behaviors from making non-consensual sexual contact with another resident (R2) and failed to protect other vulnerable residents (R4, R5), from inappropriate sexual behaviors by another resident (R1). These failures affect four (R1, R2, R4, R5) of eight residents reviewed for abuse in the sample list of eight residents. These failures resulted in (R1) having unrestricted access to (R2) resulting in (R2) being sexually abused by (R1). […]

• Actual harm, isolatedF689Feb 6, 2026

  Based on observation, interview, and record review the facility failed to ensure a resident was properly supervised during a transfer with a mechanical lift. This failure resulted in a fall for one resident (R1) of three reviewed for accidents, causing an acute break to both sides of the nasal bones as well as a break in the nasal septum and a laceration to the nose. Findings Include:The facility's Policy and Procedure for Use of a Mechanical Lift, dated November 1, 2025, and revised September 2, 2025, states the purpose of using a mechanical lift is to assist in lifting residents who are too heavy to lift manually, to promote comfort, and to maintain proper body alignment while residents are being moved. […]

• Actual harm, isolatedF689Sep 25, 2023

  Based on interview and record review the facility failed to ensure one resident (R1) of three residents reviewed for accidents in a sample list of three was not entrapped in the mechanism of a recliner chair prior to lowering the footrest. This failure caused (R1) to sustain a 12 Centimeter laceration requiring 13 sutures to close. Findings include: R1's Diagnoses list printed 9/25/23 includes the following diagnoses: Age-Related Osteoporosis, Hypertension, Gastro-Esophageal Reflux Disease, Anxiety Disorder, Chronic Atrial Fibrillation, Repeated Falls, and Dementia. […]

• Actual harm, isolatedF689Oct 18, 2022

  Based on observation, interview and record review the facility failed to provide supervision and proper transfer technique during toileting to prevent a fall for one (R1) of three residents reviewed for falls on the sample list of three. This failure resulted in R1 sustaining a fractured right humerus resulting in decreased mobility and pain. Findings include: R1's undated care plan documents; admission to the facility on [DATE] for rehabilitation of a pelvic fracture and prior to admission R1 lived at home independently. R1's admission weight is documented as 103.5 pounds and R1's admission care plan documents R1 is to have the assistance of 2 staff with a gait belt used at all times for transfers. […]

• Actual harm, isolatedF744Jun 8, 2022

  Based on observation, interview, and record review the facility failed to implement interventions for known behaviors of a resident (R4) with Dementia. This failure resulted in R1 falling from the bed and sustaining a right [CONDITION(S)]. R1 and R4 are two of four residents reviewed for falls in the sample list of 4. Findings include: The facility's Incident Report Form - IDPH (Illinois Department of Public Health) Notification dated 5/18/22 documents R1 rolled out of bed in the early morning on 5/18/22. R1 later complained of pain and was hospitalized on [DATE] at 12:30 PM. […]