Twin Lakes Therapy and Living

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 1, 2024

  Based on observation, interview, and record review, the facility failed to monitor and supervise a moderately cognitively impaired resident to prevent elopement, for 1 (Resident #1) of 6 sampled residents. The lack of an effective monitoring plan resulted in Resident #1 eloping from the facility and being found approximately .25 miles from the facility on 10/19/2024. The facility staff was not aware that Resident #1 left the facility due to Resident #3 entering a code into the exit panel, disengaging the locking mechanism on the door, and Resident #1 exited without the electronic wander management system alarming. […]

• Immediate jeopardy, isolatedF689Mar 15, 2024

  49689 Based on observations, interviews and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #20) of 2 sampled residents. This resulted in a finding of a past noncompliance Immediate Jeopardy. The Facility's Administrator was notified of the findings of a past noncompliance Immediate Jeopardy on 02/07/2024. The findings are: Resident #20 had diagnoses of Psychophysiological insomnia, Dementia severity with agitation, Psychotic disturbance, Mood disturbance, and Anxiety. According to a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/24 revealed the resident received a score of 03 (severe cognitive impairment) on the Brief Interview of Mental Status (BIMS). […]

• No harm, potential for more than minimal, widespreadF812Jun 12, 2025

  Based on observation, and interview the facility failed to ensure that cross contamination did not occur to ensure meals were served in a sanitary manner during lunch service for one of one kitchen. During an observation of the lunch meal service on 06/10/2025, the following was observed: a. At 11:40 AM, Dietary Aide (DA) #13 was using a thermometer to obtain temperatures of food items on the steam table. While testing the regular pork and fried rice, DA #13 was observed pushing the entire thermometer, including the top portion that was being held and had not been sanitized before use, into the food intended to be served to residents. b. At 12:00 PM, this surveyor observed that the mechanical soft pork was piled above the top of the tray containing it on the steam table. […]

• No harm, potential for more than minimal, patternF838Jun 12, 2025

  Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure sufficient staffing, as evidenced by the schedule not being informed by the facility assessment for 2 months, July 2024 and January 2025, which included 18 night shifts. The findings include: A review of a facility policy titled, Facility Assessment dated 01/01/2025, indicated they had an average daily census of 45. Common diagnoses of the facility's residents included mental disorders, cardiac disorders, respiratory disorders, skin disorders, cancers, musculoskeletal disorders, fractures, and gastrointestinal disorders. […]

• No harm, potential for more than minimal, patternF838Nov 1, 2024

  Based on facility document review, and interviews, the facility failed to review and update the facility assessment at least annually and failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents. This deficient practice had the potential to affect all residents of the facility. The total census was 46 residents. Findings include: A review of a facility document titled, Facility Assessment Tool, dated 09/2023, indicated the purpose was to identify resources necessary to provide care and services required by residents residing in the facility. Section titled, Staff training/education and competencies, on page 9 and 10, revealed no training on resident wandering or elopement. […]