Inspection visit
Inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. R11 stated he will often forgo activities or community outings if R5
is going because he doesn't want to be subjected to the negativity. R11 stated he has not complained about
this to anyone in particular but staff are around and have heard these comments. R11 states staff tell R5 to
stop but he just keeps doing it.
On 6/24/24 at 1:25 PM R1 stated R5 does talk all of the time, is disruptive, and does make derogatory and
racist comments about Chinese people. R1 stated it does bother her and she wishes that he would stop.
R1's Medical Diagnoses list dated June 2024 documents R1 is diagnosed with Depression, Insomnia, and
Obsessive Compulsive Disorder. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact.
R11's Medical Diagnoses list dated June 2024 documents R11 is diagnosed with Diabetes. R11's Minimum
Data Set, dated [DATE] documents R11 is cognitively intact.
R5's Medical Diagnoses list dated June 2024 documents R5 is diagnosed with Depression, Cerebral Palsy,
and Mental Disorder. R5's Minimum Data Set, dated [DATE] documents R5 is moderately cognitively
impaired.
On 6/24/24 at 1:30 PM V1 Administrator stated she had not been told about any prejudice or derogatory
remarks made by R5 but will begin an investigation into the allegation.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
145466
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145466
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twin Lakes Extended Care
310 Eads Avenue
Paris, IL 61944
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
On 6/25/24 at 11:30 AM V1 Administrator stated she is conducting the investigation from the complaints of
R1 and R11 and feels it is a resident rights issue. Residents have the right to be comfortable in their home
and R5 should not be making comments that create a bad or negative atmosphere for others. Staff need to
be more vigilant and intervene when necessary. V1 confirmed when R5 makes negative and prejudice
comments it can impede on other resident's right to dignity.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145466
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145466
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twin Lakes Extended Care
310 Eads Avenue
Paris, IL 61944
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
Findings include:
The Facility provided Respiratory Assessment Policy dated 8/2003 documents that respiratory
assessments and interventions are to be documented in the resident's medical record.
R183's undated diagnoses sheet documents diagnoses including Chronic Obstructive Pulmonary Disease
and Chronic Respiratory Failure.
R183's care plan dated 6/19/2024 documents to monitor R183 for signs and symptoms of respiratory
distress and to report to the physician changes in respiratory condition including respirations, pulse
oximetry, tachycardia, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis,
cough, pleuritic pain, accessory muscle usage and skin color.
R183's progress notes document on 6/24/24 an oxygen saturation level of 88 percent.
On 6/23/24 at 9:33AM, R183 appeared short of breath. Her color was pale, and she was using abdominal
muscles to breathe. R183 was sitting up in the bed with oxygen at one liter being administered via nasal
canula. The oxygen tubing nor water was dated, and the tubing was laying on the floor.
On 6/23/24 at 9:35AM, R183 stated, This is a bad breathing morning.
On 6/23/24 at 1:30PM, R183 remained in bed, resting her eyes and pursed lip breathing (breathing
technique).
On 6/24/24 at 10:35AM, R183 appears very short of breath and gray in color. R183 is breathing with
accessory muscles and cannot speak due to shortness of breath. R183's oxygen continues at one liter per
nasal cannula and the tubing, nor the water is dated.
On 6/24/24 at 10:36AM, V15 Certified Nursing Assistant was taking R183's vital signs. R183's oxygen
saturation was 89 percent on one liter of oxygen and her pulse rate was 125 beats per minute. R183 was
not able to speak and was gasping. R183 is opening and closing her eyes and appears very uncomfortable.
On 6/24/24 at 10:38AM, V2 Director of Nursing (DON) said that she had a discussion with R183 and V16
(Family Member) about hospice and comfort care options but that they were not wanting that at this time.
When asked about the plan for R183's comfort during periods of air hunger, V2 DON said that it was a
difficult situation to manage.
On 6/24/24 10:40AM V4 Licensed Practical Nurse (LPN) stated, I just turned her oxygen up to two liters
because of her vital signs. I will notify the doctor.
On 6/24/24 11:00AM, V1 Administrator stated, I went down, and her coloring isn't good, and she
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145466
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145466
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twin Lakes Extended Care
310 Eads Avenue
Paris, IL 61944
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
doesn't look comfortable to me. We are going to send her to the ER.
Level of Harm - Minimal harm
or potential for actual harm
On 6/24/24 3:50PM V3 LPN stated, I saw that she was struggling before she went to the hospital and I'm
sure that it is the Lasix (diuretic) that made the difference.
Residents Affected - Few
On 6/25/24 at 9:30AM, R183's coloring is much improved to pale pink and R1 is able to speak while
breathing more easily.
On 6/25/24 at 9:31AM, R183 said that she was very scared yesterday and that she received an extra dose
of Lasix (diuretic) in the hospital and that seems to have helped.
On 6/25/24 at 10:44AM, R183's oxygen remains undated.
On 6/25/24 at 10:45AM, V11 LPN stated, Oxygen tubing is supposed to be labeled weekly. They usually do
it on nights.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145466
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145466
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twin Lakes Extended Care
310 Eads Avenue
Paris, IL 61944
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based 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.
R15's Medication Administration Record (MAR) for June 2024 includes the following active physician's
orders for Psychotropic Medication: Sertraline HCL (antidepressant) Give 75 milligrams by mouth one time
a day. Aripiprazole (antipsychotic) 20 milligrams by mouth in the morning.
There is no documentation of psychotropic assessments observed for R15. No targeted behaviors are
identified or tracked for R15. No non-pharmacological interventions are documented as initiated for R15.
2. R20's Care Plan revised 6/5/24 includes the following diagnoses: Dementia with Agitation and Major
Depressive Disorder.
R20's Medication Administration Record (MAR) for June 2024 includes the following active physician's
orders for Psychotropic Medication: Fluoxetine HCl (antidepressant) Oral Capsule 40 MG Give 80 mg by
mouth one time a day. Quetiapine (antipsychotic) 25 MG Tab Give 12.5 mg by mouth two times a day.
Divalproex Sodium DR (neuroleptic) 125 MG Give 1 tablet by mouth two times a day for dementia with
behaviors.
R20's most recent Psychotropic Medication Assessment is dated 9/29/23 and includes only the Fluoxetine.
No targeted behaviors are identified or tracked for R20. No non-pharmacological interventions are
documented as initiated for R20.
On 6/25/24 at 10:01AM V16, Care Plan Coordinator stated I wasn't aware I needed to do quarterly
assessments for residents with psychotropic medications. I will be doing the assessments and documenting
specific behaviors and non-pharmacological interventions in the future. I do see this was not done for (R15
and R20).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145466
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145466
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twin Lakes Extended Care
310 Eads Avenue
Paris, IL 61944
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
R6 's undated physician order sheet documents an order for Morphine 20 milligrams per milliliter per 30
milliliter bottle, administer .25 milliliters, sublingually as needed, every four hours as needed for pain.
On [DATE] at 9:30AM, two bottles of Morphine Sulphate were in cart two's narcotic box. One bottle had 13
cubic centimeters of medication left in it and one bottle was full with 30 cubic centimeters in it. Both bottles
had expiration dates of [DATE].
On [DATE] at 9:35AM, V4 Licensed Practical Nurse stated, They are expired. It should have been
destroyed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145466
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145466
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Twin Lakes Extended Care
310 Eads Avenue
Paris, IL 61944
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based 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.
Findings include:
Historical room documentation and actual onsite measurements on 6/25/24 at 12:00PM with V13
Maintenance Director, determined rooms 2, 4 through 11, and 14 through 32 are undersized; providing
either 73.11 square feet per resident bed in rooms 9-11, 14-24; and 75.65 square feet in rooms 2, 4-8,
25-32.
The most recent Centers for Medicare and Medicaid Services Certification and Transmittal undated,
documents 56 of the facility's 62 beds are certified Title 18 (Medicare) and/or Title 19 (Medicaid). Rooms 2,
and 4 through 11 are double occupancy and dually certified for Medicare and Medicaid, while rooms 14
through 32 are double occupancy and certified for Medicaid.
The facility's Daily Roster dated 6/23/24, documents 31 of these 56 certified beds are occupied by
residents residing in the facility.
On 6/25/24 at 11:30AM, R18 said that his room was big enough for one person, but not two people.
On 6/25/24 at 11:32AM, R19 said that his room is big enough for two people and that he wouldn't mind
having a roommate.
On 6/25/24 at 11:35AM, R6 said that his room is big enough for himself but that he could not have another
person in it because it would be too small.
On 6/25/24 at 12:42PM, R4 said that she and her roommate get along well and that there is enough room
for the two of them.
On 6/25/24 at 12:43PM, R1 said that her room isn't really very big and that she and her roommate don't
have enough space, but the facility can't help it because her roommate has to have a bed.
On 6/25/24 at 12:44PM, R14 said that she shares with a roommate and that the space is ok.
On 6/25/24 at 12:45PM, R12 and R17 said that they have enough room in their room.
On 6/25/24 at 3:00PM, V14 Regional Director of Operations said that she was aware that some of the
facility rooms do not meet the size requirement per resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145466
If continuation sheet
Page 7 of 7
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Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
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.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the June 25, 2024 survey of TWIN LAKES EXTENDED CARE?
This was a inspection survey of TWIN LAKES EXTENDED CARE on June 25, 2024. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TWIN LAKES EXTENDED CARE on June 25, 2024?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.