Twin Lakes Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jan 2, 2026

  Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, and failed to ensure a safe route of egress through emergency exit doors for residents on two of three units ([NAME] and [NAME] units), which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. Findings include: The facility's policy regarding exits or means of egress, dated July 28, 2025, indicated that the facility had designated exits for each area of the building to allow for rapid evacuation. Exit doors would remain unlocked at all times and residents were never denied access to unlocked exits. […]

• Immediate jeopardy, patternF600Dec 7, 2022

  Based on a review of facility policies, clinical records, and information submitted by the facility, as well as resident and staff interviews, it was determined that the facility failed to promptly take measures necessary to protect residents from verbal and physical abuse after abuse was identified for two of 47 residents reviewed (Residents 71, 73). This failure placed the residents in immediate jeopardy due to the actual verbal and physical abuse that already occurred, as well as the potential for further verbal and physical abuse to occur. […]

• Actual harm, isolatedF742Dec 7, 2022

  Based on clinical record reviews as well as interviews with staff, it was determined that the facility failed to adequately monitor, assess, and provide the necessary and timely behavioral health care and services for residents exhibiting psychological and/or physical distress for two of 47 residents reviewed (Residents 71 and 73). Findings include: Nursing notes, dated April 7, 2022, revealed that Resident 71 and Resident 73 arrived at the facility around the same time and were placed in the same room together. Resident 71 is the mother of Resident 73. Interview with Family Member 1 on December 6, 2022, at 1:45 p.m. revealed that Resident 73 had no power of attorney or legal guardian. […]

• Actual harm, isolatedF684Jan 12, 2022

  Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, by failing to adequately monitor residents' bowel function and to ensure that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A quarterly MDS assessment for Resident 41, dated November 24, 2021, revealed that the resident was cognitively impaired, required staff assistance for toileting, and was always incontinent of bowel. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF585Apr 17, 2026

  Based on review of facility policy, clinical records and grievances, as well as staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance for one of 7 residents reviewed (Resident 2).Findings include:The facility's policy regarding grievances/complaints, filing, dated April 8, 2026, revealed that residents and family members may file a grievance and that the grievance will be resolved within five working days.A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 17, 2025, revealed that the resident was cognitively intact, required assistance for daily care needs, and had a full set of dentures. […]