Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Lakes Therapy And Living during CMS and state inspections, most recent first.
Multiple instances of cross contamination occurred during meal service, including improper use of a food thermometer, trays touching food, and staff handling food with contaminated hands. Staff and management confirmed these actions were not in line with proper food handling, and the facility lacked a policy on cross contamination.
The facility did not maintain sufficient CNA staffing on night shifts as determined by its own facility assessment, with multiple shifts in July and January falling below the required CNA-to-resident ratio for a population with complex care needs. Staff interviews confirmed that these shortages led to residents being found soiled and still in bed at shift changes, and that staffing issues were ongoing prior to new leadership.
A resident who was dependent on staff for toileting hygiene did not receive timely incontinent care after requesting assistance from a CNA, resulting in the resident remaining soiled for several hours overnight. The resident was later found with dried bowel movement and skin irritation, and documentation and interviews revealed ongoing issues with delayed care and unanswered call lights.
A resident with a physician's order for contact precautions due to ESBL was assisted by a CNA who failed to use required PPE when entering the room and during direct care, despite clear signage and available supplies. The CNA only donned PPE after realizing the oversight, and also removed a lunch tray from the room without following isolation protocols. Facility staff interviews and policy reviews confirmed the expectation for PPE use, but the required infection control measures were not followed.
A resident with severe cognitive impairment eloped from a facility after another resident entered a code into the exit panel, allowing the impaired resident to exit without triggering the electronic wander management system. The facility failed to implement effective monitoring and supervision, and staff were unaware of which residents were at risk for elopement. The wander management system was not functioning as intended, contributing to the incident.
The facility failed to update its assessment annually, missing crucial information on resident wandering and elopement, despite having a Memory Care Neighborhood. This oversight was evident when a resident exited the facility unnoticed. The assessment inaccurately listed resources and omitted the electronic wander management system installed earlier in the year.
Cross Contamination During Meal Service
Penalty
Summary
During a lunch meal service, multiple instances of cross contamination were observed in the facility's kitchen. A dietary aide used a thermometer to check food temperatures, inserting the entire device—including the unsanitized top portion—directly into food intended for residents. Additionally, the same aide repeatedly allowed the bottom of food trays to come into contact with mechanical soft pork while portioning, resulting in food residue on both the trays and the serving line. Another aide was seen handling coffee, silverware, and condiments, then touching chicken tenders with contaminated hands after the food slipped, without performing hand hygiene until after the meal service was completed. There was also an incident where regular pork fell into a tray of regular carrots, which continued to be served to residents, including those on mechanical diets. Interviews with the dietary aides and the dietary manager confirmed that these actions constituted cross contamination and were not in line with proper food handling practices. The dietary manager acknowledged that the facility did not have a policy or procedure addressing cross contamination, and staff recognized that their actions could lead to the spread of germs or illness. No information was provided regarding any residents' medical history or condition at the time of the deficiency.
Failure to Ensure Sufficient Staffing According to Facility Assessment
Penalty
Summary
The facility failed to ensure sufficient staffing as required by its own facility assessment and policy, particularly during night shifts in July 2024 and January 2025. The facility assessment identified a resident population with complex needs, including mental, cardiac, respiratory, skin, cancer, musculoskeletal, and gastrointestinal disorders. Specific acuity factors included residents requiring oxygen, updraft treatments, behavioral health interventions, injections, ostomy care, hospice, respite care, and parenteral nutrition. The assessment also documented that a significant number of residents required assistance with activities of daily living such as dressing, bathing, transfers, eating, and toileting. The facility's own standards called for a CNA-to-resident ratio of 1:13 on night shifts, but staffing schedules for the months reviewed showed multiple instances where only two or three CNAs were scheduled for night shifts with resident censuses ranging from 40 to 47, which did not meet the assessed staffing needs. Interviews with staff, including LPNs, RNs, CNAs, the DON, and the Administrator, confirmed that staffing shortages were a known issue prior to the hiring of new leadership. Staff reported that these shortages resulted in residents being found soiled and still in bed at the start of shifts. The facility's policy on sufficient and competent staffing stated that staffing numbers and skill requirements should be based on resident needs as determined by care plans, resident assessments, and the facility assessment, but the documented schedules did not align with these requirements for the periods in question.
Failure to Provide Timely Incontinent Care Resulting in Neglect
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for toileting hygiene and incontinent care was not provided timely assistance. The resident, who was cognitively intact and at risk for skin breakdown, requested incontinent care from a CNA during the night shift. The CNA checked the resident with a flashlight, stated that the resident was fine, and did not provide the requested care. The resident remained soiled with dried bowel movement from the back down to the ankles until the next shift, when two other CNAs discovered the situation and provided care. Documentation showed a significant gap between the last recorded incontinent care and the next, spanning several hours overnight. Further review revealed that the resident's skin was red and raw, requiring the application of a zinc barrier cream. Facility records and interviews indicated that this was not an isolated incident, as multiple CNAs reported delays in providing timely care, and several grievances had been filed regarding long wait times for assistance. The facility's own policy defined neglect as the failure to provide necessary goods and services to avoid physical harm or mental anguish, which was not adhered to in this case.
Failure to Implement Contact Precautions for Resident with ESBL
Penalty
Summary
The facility failed to ensure that transmission-based precautions were implemented as ordered for a resident who tested positive for Extended-Spectrum Beta-Lactamases (ESBL) in their urine. The resident had a physician's order for contact precautions, including the use of gloves, gown, eye protection, and mask for a specified period. Despite clear signage and the availability of personal protective equipment (PPE) at the resident's room, a Certified Nursing Assistant (CNA) was observed entering the room, delivering a lunch tray, and assisting with a transfer without donning the required PPE. During the transfer, the CNA's and resident's clothing came into contact, and the CNA only donned PPE after realizing the oversight when returning to the room. The CNA also removed the lunch tray from the room without using a biohazard bag, as required for contact isolation protocols. Interviews with the CNA, the Treatment Nurse, and the Administrator confirmed that the facility's process for contact isolation includes signage, PPE availability, and staff notification, with the expectation that staff don PPE before entering the room. Facility policies reviewed indicated that staff and visitors are required to wear gloves and gowns upon entering rooms under contact precautions. The deficiency was identified through direct observation, record review, and staff interviews, demonstrating a failure to follow established infection prevention and control protocols for a resident with a multidrug-resistant organism.
Resident Elopement Due to Inadequate Supervision and System Failure
Penalty
Summary
The facility failed to adequately monitor and supervise a moderately cognitively impaired resident, leading to the resident's elopement. The resident, who had a history of severe cognitive impairment and was at high risk for elopement, managed to leave the facility without staff knowledge. This occurred when another resident, who was cognitively intact, entered a code into the exit panel, allowing the impaired resident to exit the facility. The electronic wander management system did not alarm as expected, indicating a failure in the system or its implementation. The resident was found approximately 0.25 miles from the facility, having exited without staff awareness. The facility's policies on accidents, incidents, and elopements were not effectively implemented, as evidenced by the lack of a detailed monitoring plan for the resident at risk of elopement. The facility's staff, including the Director of Nursing, were not aware of which residents were at risk for elopement, and there was no list of residents with exit-seeking behaviors or those who had electronic wander management transmitter devices. The facility's electronic wander management system, which was supposed to prevent such incidents, was not functioning as intended. Despite the system being in place, the resident was able to leave the facility without triggering an alarm. The maintenance director and other staff were not adequately trained or informed about the system's operation, and there were reports of previous malfunctions that were not addressed. The facility's failure to ensure the proper functioning of the wander management system and to maintain adequate supervision and monitoring of residents at risk for elopement directly contributed to the incident.
Failure to Update Facility Assessment and Address Wandering Risks
Penalty
Summary
The facility failed to review and update its facility assessment at least annually, which is necessary to ensure that the resources required to meet the needs of residents are accurately identified and allocated. The Facility Assessment Tool, dated September 2023, did not include training on resident wandering or elopement, despite the presence of a Memory Care Neighborhood where such training is crucial. Additionally, the assessment inaccurately listed resources such as ventilators and a dialysis chair, which the facility did not possess, and failed to include the electronic wander management system installed in March 2024. This deficiency was highlighted by an incident involving a resident who exited the facility without staff knowledge on October 19, 2024. The facility's policy on Wandering and Elopements requires identifying residents at risk and updating care plans with interventions to maintain safety, but the Facility Assessment Tool did not address these issues. Interviews with the Wander Management System Provider and the Nurse Consultant confirmed the lack of updates to the facility assessment, which should reflect the current status and needs of the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Flippin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside At The Springs | 5.7 mi | ★★★★★ | 0 | 0 |
| Gassville Therapy And Living | 6.3 mi | ★★★★★ | 4 | 0 |
| Hiram Shaddox Health And Rehab | 12.4 mi | ★★★★★ | 0 | 0 |
| Care Manor Nursing And Rehab | 12.5 mi | ★★★★★ | 5 | 0 |
| Lake Forest Senior Living At Mountain Home | 14.6 mi | ★★★★★ | 0 | 0 |
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