Inspection Reports for
Twin Lakes Therapy and Living

The complaint investigation substantiated neglect related to incontinent care for Resident #5. The facility conducted an internal investigation, suspended involved staff, and re-educated them. Staffing issues prior to new leadership were acknowledged by multiple staff and administrators.

The facility failed to ensure residents were free from neglect, as Resident #5 was found soiled with dried bowel movement after a request for care was ignored during the night shift. Additionally, the facility failed to ensure sufficient staffing, with schedules not informed by facility assessments for multiple months, impacting resident care.

The facility failed to prevent cross contamination during lunch meal service, with multiple observations of dietary aides contaminating food and trays. Additionally, the facility failed to ensure proper use of transmission-based precautions for a resident with a multidrug resistant infection, with staff not using required personal protective equipment (PPE) consistently.

The complaint investigation was substantiated. The immediate jeopardy began on 10/19/2024 when Resident #1 eloped from the facility after Resident #3 entered the exit code, disengaging the door lock without alarm activation. Resident #1 was found approximately 0.25 miles from the facility with injuries. The facility failed to have an effective monitoring plan and did not know which residents were at risk or have a list of such residents. The electronic wander management system was malfunctioning and not properly monitored. Staff failed to report or act timely on known risks and behaviors. The facility did not conduct a root cause analysis or QAPI for the elopement.

The facility failed to adequately monitor and supervise a resident at risk for elopement, resulting in the resident leaving the facility undetected and being found off-site with injuries. The electronic wander management system failed to alarm due to a resident entering the exit code, and staff were unaware of residents at risk or the door code being used improperly. The facility also failed to maintain an updated facility assessment reflecting current resident risks and resources.

The facility was found deficient in multiple areas including failure to keep call lights within reach, untimely reporting of an elopement, inadequate showering and hygiene care, failure to follow wound care orders, improper foot care, inadequate supervision leading to elopement with immediate jeopardy, unlocked hazardous areas, failure to provide dietary preferences and snacks consistently, and maintenance issues creating safety hazards.

The facility was found deficient in multiple areas including call light accessibility, failure to provide Advance Beneficiary Notices, untimely reporting of an elopement, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, failure to provide scheduled showers, improper wound care, inadequate foot care, inadequate supervision leading to elopement, medication management issues including missing medications and inaccurate narcotic records, failure to provide scheduled snacks, improper infection control practices, and environmental safety hazards.

The complaint investigation found substantiated medication errors involving Resident #1 receiving incorrect doses of Ativan on multiple occasions, confirmed by interviews with the resident, nursing staff, and the Director of Nursing.

The facility failed to ensure staff followed physician medication orders for one sampled resident, resulting in multiple medication errors where the resident received incorrect doses of Ativan. Interviews and record reviews confirmed these errors and subsequent notifications to relevant parties.

The facility failed to ensure individualized comprehensive care plans were implemented and updated for residents, failed to maintain safe equipment such as call light cords, and did not ensure oxygen and BI-PAP respiratory equipment were used and stored according to physician orders and professional standards.