All citations for Twin Lakes Therapy and Living

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Twin Lakes Therapy and Living

Last standard health inspection on record

June 12, 2025

Showing 1 to 25 of 27 citations

  1. Immediate jeopardy to resident health or safety

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of November 1, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 16, 2024).

  2. Immediate jeopardy to resident health or safety

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of March 15, 2024. Found during a standard inspection and a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (March 14, 2024).

  3. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Widespread (many residents). CMS level F.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of June 12, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 12, 2025).

  4. No harm, with potential for more than minimal harm

    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0838, Administration Deficiencies. Inspection of June 12, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (July 12, 2025).

  5. No harm, with potential for more than minimal harm

    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0838, Administration Deficiencies. Inspection of November 1, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 16, 2024).

  6. No harm, with potential for more than minimal harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 15, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  7. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of March 15, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  8. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of March 15, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  9. No harm, with potential for more than minimal harm

    Provide appropriate foot care.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0687, Quality of Life and Care Deficiencies. Inspection of March 15, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  10. No harm, with potential for more than minimal harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0755, Pharmacy Service Deficiencies. Inspection of March 15, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  11. No harm, with potential for more than minimal harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0757, Pharmacy Service Deficiencies. Inspection of March 15, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  12. No harm, with potential for more than minimal harm

    Ensure medication error rates are not 5 percent or greater.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0759, Pharmacy Service Deficiencies. Inspection of March 15, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  13. No harm, with potential for more than minimal harm

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of March 15, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  14. No harm, with potential for more than minimal harm

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0809, Nutrition and Dietary Deficiencies. Inspection of March 15, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  15. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of March 15, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  16. No harm, with potential for more than minimal harm

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0921, Environmental Deficiencies. Inspection of March 15, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  17. No harm, with potential for more than minimal harm

    Provide safe and appropriate respiratory care for a resident when needed.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of January 27, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 17, 2023).

  18. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of June 12, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 12, 2025).

  19. No harm, with potential for more than minimal harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of June 12, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (July 12, 2025).

  20. No harm, with potential for more than minimal harm

    Reasonably accommodate the needs and preferences of each resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0558, Resident Rights Deficiencies. Inspection of March 15, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  21. No harm, with potential for more than minimal harm

    Ensure each resident receives an accurate assessment.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of March 15, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  22. No harm, with potential for more than minimal harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of March 15, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  23. No harm, with potential for more than minimal harm

    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0807, Nutrition and Dietary Deficiencies. Inspection of March 15, 2024. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (April 8, 2024).

  24. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of January 27, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 17, 2023).

  25. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of January 27, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 17, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.