Twin Lakes Extended Care

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to protect a resident's right to dignity for two of two residents (R1, R11) by another resident (R5) reviewed for dignity in the total resident sample list of 27. Findings Include: The State of Illinois Ombudsman Program, Resident Rights in Long Term Care Facilities dated 11/2018 documents that all residents have a right to dignity and respect and the facility must care for residents in a manner that promotes their quality of life. The facility must provide services to keep each resident's mental health at the highest practical level. On 6/24/24 at 1:20 PM R11 stated R5 is very loud and constantly talking and he makes derogatory and prejudice comments as well as false comments. R11 states this makes him uncomfortable, bothers him a lot and also bothers others in the room. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement interventions in response to signs and symptoms of shortness of breath for a resident and ensure respiratory tubing is maintained in a sanitary manner for a resident receiving oxygen therapy. These failures affect one (R183) of three resident's reviewed for respiratory care from a total sample list of 27 residents.

Inspectors wroteBased on interview and record review the facility failed to document psychotropic medication assessments, identify and track targeted behaviors, and attempt non-pharmacological behavioral interventions for two (R15, R20) of five residents reviewed for psychotropic medication in a sample list of 27 residents. Findings Include: The facility's policy Psychotropic Medication Policy revised 11/28/17 states Residents who receive antipsychotic drugs shall receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Any resident receiving psychotropic medications will be reviewed at minimum of every quarter by the interdisciplinary team. 1. R15's Care Plan revised 6/25/24 includes the following diagnoses: Major Depression and Mild Dementia with Anxiety. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of expired schedule two narcotics for one (R6) of three residents reviewed for medications from a total sample list of 27 residents. Findings Include: The facility provided Procurement and Storage of Medications Policy dated [DATE] documents that all discontinued/expired non-controlled medications are to be removed from the active medication storage area, and the quantity should be noted on the medication sheet. All medications should then be returned to pharmacy or destroyed per facility policy as soon as practical. All controlled substances are to be destroyed according to the facility policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space per resident bed in 28 of 56 resident rooms at the facility, 28 of these rooms were occupied by residents. This failure affects all 31 residents residing in the facility.

Inspectors wroteBased 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). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a full time licensed Administrator. This failure has the potential to affect all 33 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to follow its Abuse Prohibition Policy by failing to determine the risk of abuse for six of eight residents (R1, R2, R3, R4, R7, and R8) reviewed for abuse on the sample list of eight.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's power of attorney of a change in dosage of an antipsychotic medication and a change in behavior for one of eight residents (R1) reviewed for change in resident condition in a sample of eight.

Inspectors wroteBased on interview and record review the facility failed to report allegations of resident to resident abuse to the Administrator for three (R1, R4, and R5) of eight residents reviewed for abuse in the sample list of eight.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to implement/update interventions following an accident/fall for two residents (R1, R3) of three residents reviewed for care plans in a sample list of three residents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain proper sanitation of serving utensils. This failure has the potential to affect all 36 residents residing in facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide bedrooms that measure at least 80 square feet per resident bed for 28 resident rooms 2,4-11, and 14-32.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a comprehensive care plan for four of 12 residents (R15, R16, R21, R33) reviewed for care plans in the sample list of 22.

Inspectors wroteBased on interview and record review the facility failed to complete wound treatments for one of four residents (R5) reviewed for wound care in the sample list of 22 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to transcribe physician orders and complete wound treatments and pressure risk assessments for one of four residents (R33) reviewed for wound care in a sample list of 22 residents.

Inspectors wroteBased on interview and record review, the facility failed to deliver mail to residents on Saturdays. This failure has the potential to affect all 36 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide the required eight hours of Registered Nurse staffing coverage per 24-hour period for three of fifteen days reviewed for staffing. This failure has the potential to affect all 33 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician of low blood sugar and that insulin was not administered for one (R28) of five residents reviewed for unnecessary medications in the sample list of 20.

Inspectors wroteBased on observation, record review and interview the facility failed to conduct periodic safety inspections of side rails in use for six residents (R20, R11, R184, R19, R22, and R28) of seven residents reviewed for side rails in a sample of 20 residents. Findings Include: Physician's Order Sheets for R20, R11, R184, R19, R22, and R28 dated 5/1/22 through 5/31/22 include physician's orders for half side rails to enable residents to assist with bed mobility. On 5/17/22 at 11:00AM R22 was not in her bed, but the half side rails were up and in place to both sides of the bed. The rails were attached loosely to the bed by only the adjustment handle in the center of the rails. The rail could be turned in a complete circle by gentle pressure to either end of the rail. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a care plan for anticoagulant use for one (R11) of 20 residents reviewed for care plans in the sample list of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to administer a nutritional supplement and accurately assess for significant weight loss for two (R32, R22) of four residents reviewed for nutrition in the sample list of 20. 1. R22's May 2022 Physician's Orders document R28's diet includes a frozen nutritional supplement with lunch and supper. R22's 2021 Weight Log documents R22 weighed 193.5 lbs (pounds) in August, 188 lbs in November and 193 lbs in December. R22's 2022 Weight Log documents R22 weighed 188 lbs in January, 165.7 lbs in February (an 11.8% loss in 1 month, and 14.37% loss in 6 months), and 166.2 lbs in March (13.89% loss in 3 months). R22's March and May 2022 Medication Administration Records document R22 weighed 163.4 lbs on 3/22, and 169.2 lbs on 5/10. R22's Dietary Notes document the following: [...]

Inspectors wroteBased on observation, interview and record the facility failed to safely install side rails for two residents (R18, R22) of seven residents reviewed for side rails in a sample list of 20 residents. Findings Include: 1. R18's Bed Rail assessment dated [DATE] documents R18 uses side rails to promote independence in turning from side to side. R18's Minimum Data Set (MDS) dated [DATE] documents R18 is moderately cognitively impaired and requires an extensive assist of staff to complete bed mobility and transfer. On 5/16/22 at 10:30AM R18 was in bed. Half side rails were up and in place to both sides of the bed. R18 was lying on her left side. Her mattress had slipped to the left side leaving a six inch gap between the edge of the mattress and the side rail. The springs on the bed were exposed in this gap. [...]

Inspectors wroteBased on interview and record review the facility failed to identify specific behaviors and targeted nonpharmacological interventions to warrant the use of psychotropic medications and failed to complete psychotropic medication assessments for one of five residents (R29) reviewed for unnecessary medications in the sample list of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nursing staffing information. This failure has the potential to affect all 33 residents in the facility.