Twin Lakes Memory Care

The facility failed to maintain accurate records for the receipt, administration, and disposition of controlled substances. Specifically, for one resident, the electronic medication administration record showed 18 doses of Norco administered, while the controlled substance count sheet recorded 29 doses signed out, preventing accurate reconciliation.

The facility failed to maintain accurate and readily retrievable records for the administration of controlled substances. Specifically, for one resident, the number of doses recorded on the controlled substance count sheet (29) did not match the number of doses documented on the electronic medication administration record (18).

The facility failed to ensure that housekeeping storage rooms and closets were locked and inaccessible to residents. Specifically, hazardous cleaning agents, disinfectants, and laundry products were found on open shelves in unlocked spa and laundry rooms. This lack of secure storage created a risk of residents ingesting, inhaling, or handling dangerous substances.

The facility failed to provide separate locked areas for storing hazardous cleaning agents and substances. Observations in the Special Care Unit spa rooms revealed unlocked access to spray disinfectants, bath gels, and air neutralizers labeled with caution or danger warnings.