Twin Lakes Rehabilitation and Nursing

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF684May 3, 2023

  Based on resident interview, staff interview, and clinical record review, the facility staff failed to obtain orders for the care and treatment of a colostomy for one of 20 residents, Resident #67. Findings were: Resident #67 was admitted to the facility with the following diagnoses including but not limited to: diabetes mellitus, hypertension, anxiety, depression, and gastro-esophageal reflux. An annual MDS (minimum data set) with an ARD (assessment reference date) of 04/06/2023 assessed Resident #67 as cognitively intact with a summary score of 14. On 05/02/2023 at approximately 2:15 p.m., Resident #67 was interviewed regarding life in the facility. During the conversation she stated that she had a colostomy. […]

• No harm, potential for more than minimal, patternF725Jun 10, 2021

  Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure sufficient staffing to provide resident care for 3 of 23 residents in the survey sample, Resident #74, Resident #11, and Resident #33. Resident #74, Resident #11, and Resident #33 did not receive their showers as scheduled. The findings include: 1. Resident #74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #74 as cognitively intact for daily decision making with a score of 14 out of 15. Under section G - Functional Status, the MDS assessed Resident #74 total dependent with the assistance of one person for bathing. […]

• No harm, potential for more than minimal, patternF812Jun 10, 2021

  Based on observation, staff interview and facility document review, the facility staff failed to store and prepare food in a sanitary manner. Frozen meat patties were stored uncovered and unlabeled in the freezer. Sliced cheese was stored in the refrigerator without a date opened or use by date. The manual can opener in the main kitchen was dirty. The findings include: On 6/8/21 at 11:48 a.m., accompanied by the dietary manager (other staff #2), the kitchen and food storage areas were inspected. Observed in the walk-in freezer was a large bag of frozen turkey sausage patties. The bag was open with the meat patties exposed to air. The turkey sausage patties had no manufacturer's label and no date opened or use by date posted on the bag. […]

• No harm, potential for more than minimal, isolatedF607May 3, 2023

  Based on review of employee files, staff interview, and review of facility policy, the facility failed to implement their abuse prevention policy for the screening of new employees. The facility failed to obtain a Sworn Statement from seven of 24 new hired employees. The findings were: At approximately 1:30 p.m. on 5/3/2023, a review of 24 randomly selected personnel files of facility employees hired in the last two years was conducted. Two employees from the Human Resources Department assisted in the review. Documents included in the review were the Sworn Statement, Criminal Record Check, License (if applicable), and References. The review identified seven employees who did not have a Sworn Statement in their individual personnel file. […]

• No harm, potential for more than minimal, isolatedF657May 3, 2023

  Based on staff interview and clinical record review, the facility staff failed to revise the comprehensive care plan for one of twenty residents in the survey sample (Resident #47). The findings include: Resident #47's care plan was not revised to include interventions for injury prevention following bruising to the resident's hand/finger. Resident #47 was admitted to the facility with diagnoses that included Parkinson's disease, dementia, atrial fibrillation, gout, hypertension, congestive heart failure, arthritis, and depression. […]