Twin Lakes Therapy and Living

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that transmission-based precautions were utilized as ordered for one (Resident #8) of one resident reviewed. A review of an Order Summary indicated that Resident #8 had a physician ' s order indicating contact precautions were needed because the resident had tested positive for Extended-Spectrum Beta-Lactamases (ESBL) in their urine. The order indicated personal protective equipment (PPE) should be used as follows: gloves, gown, eye protection, and mask every shift for five days from 06/525 to 06/10/2025. A review of the Lab Results Report of a urinalysis on 06/03/2025 indicated that Resident #8 was ESBL positive. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure residents were free of neglect for one (Resident #5) of three residents reviewed. Specifically, incontinent care was not provided in a timely manner.

Inspectors wroteBased 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. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to the residents. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an elopement was reported in a timely manner, which resulted in failure to ensure an investigation was promptly initiated and measures were immediately implemented to prevent further elopements for 1 (Resident #194) of 2 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident ' s individualized plan of care was revised to reflect the current needs of the resident and updated to include oxygen use for 01 (Resident #23) sample mix residents and failed to ensure positioning wedges and pressure ulcer wound were care planned for 01 (Resident #19) residents who had a pressure ulcer as documented in physician orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were showered/bathed as scheduled to promote good personal hygiene for 01 (Resident #23) sample mix resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required assistance with foot care were regularly provided with the necessary assistance to maintain good hygiene and grooming, as evidenced by failure to ensure toenails were kept clean and trimmed for 1 (Resident #5) out of 46 residents who require assistance with foot care. 1. Resident #5 had diagnoses of Peripheral vascular disease, non-rheumatic aortic valve insufficiency, and Non-rheumatic valve stenosis. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact). [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure all pharmaceuticals were available for the residents during medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medication regimens were free of unnecessary medications to prevent adverse side effects and the potential for injury for 2 (Resident #20 and #35) of 2 sampled residents.

Inspectors wroteBased on observation and record review, the facility failed to ensure physician orders were followed to maintain a medication rate of less than 5% to prevent complications for 02 (Resident # 19 and #22) of 06 residents observed during medication pass resulting in medication errors.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that medications were stored in accordance with state law and accepted principles of pharmacy laws and regulations for 1 of 2 medication carts.

Inspectors wroteAccording to observation, interview and record review, the facility failed to ensure snacks were passed at bedtime. This failed practice had the potential to affect 22 residents who are scheduled to have bedtime snacks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Bilevel Positive Airway Pressure (Bi-Pap) face masks were contained in a storage bag when not in use for 1 (Resident #38) sample mix resident; ensure personal drinks that were open and being consumed during medication pass were not in the medication cart while administering medication.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, safety, homelike environment to prevent possible injury to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach to enable residents to call for any necessary assistance for 1 (Resident #38) sample mix residents.

Inspectors wroteBased on interview and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for 01 (Resident #38) sample mix resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were followed for wound care for 1 (Resident #23) sample mix resident with orders for wound care.

Inspectors wroteBased on observation interview, and record review, the facility failed to ensure resident dietary preferences were consistently made available to promote good fluid intake for 1 (Resident #3) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure Advance Beneficiary Notice [ABN] were provided to inform the residents and/or their responsible parties of financial liability for continued care and services after their Medicare coverage was discontinued for the 3 (Resident #17, Resident #19, Resident #37) sampled residents who were discharged from Medicare Skilled services in the last 6 months and remained in the facility and/or discharged home. This failed practice had the potential to affect 20 residents who received a Beneficiary Notice and were discharged or remained in the facility the last 6 months after they were released from Medicare Services according to a list provided by the Administrator on 03/11/24 at 10:40 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was ordered and administered at a prescribed flow rate consistent with professional standards of practice for 1 (Resident #9) of 5 ( R #9, R #13, R #20, R #23, and R #251) Sample Residents who had orders for oxygen and failed to ensure a BI-PAP (Bilevel Positive Airway Pressure) mask was kept in a storage bag when not in use for 1 (Resident #20) of 3 (R #9, R #20, R #23) Sample Residents with a Physician Order for BI-PAP.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an individualized comprehensive Care Plan was implemented to meet resident's medical and nursing needs, to promote continuity of care for 1 (Resident #43). This failed practice had the potential to affect all 45 residents who had Care Plans, according to a Census list provided by the Administrator 01/23/23 at 10:15 am.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the Comprehensive Care Plan was reviewed and revised to meet the needs of the resident for 1 (Resident #9) of 5 (R #9, R #13, R #20, R #23 and R #251) sample residents reviewed who had a Physician Order for oxygen and 1 (Resident #20) of 3 sample residents (R #9, R #20, and R #23) reviewed who had Physician orders for the use of a BI-PAP [Bilevel Positive Airway Pressure].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from an electrical shock due to frayed call light cords to prevent potential shock hazard for 1 (Resident #44) sample selected residents who utilized call lights.