Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Extended Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and known communication and positioning challenges was being transferred with a mechanical lift using a sling she reportedly disliked because its fuzzy material made sliding easier. Multiple CNAs stated the resident frequently leans forward during transfers and requires repeated reminders to sit back. During the incident, one CNA operated the lift while another stood behind the resident holding the sling straps as the resident repeatedly leaned forward, yet they continued lowering her instead of stopping until she was safely positioned. The resident fell forward out of the sling, landing face-first on the lift structure and sustaining bilateral nasal bone and nasal septum fractures and a nasal laceration. Staff interviews confirmed that CNAs are trained not to proceed with a lift transfer when a resident is leaning forward or moving unsafely.
A resident with moderate cognitive impairment frequently made loud, derogatory, and prejudiced comments, causing discomfort to two other residents. Despite staff awareness, the behavior persisted, impacting the residents' dignity and comfort. The facility's administrator acknowledged the issue as a resident rights concern.
A resident with COPD and respiratory failure experienced significant distress due to inadequate respiratory care. Despite showing symptoms like shortness of breath and low oxygen saturation, the facility delayed adjusting oxygen therapy and failed to maintain sanitary conditions for the oxygen equipment. Staff were aware of the resident's condition but did not act promptly, leading to the resident being sent to the ER.
The facility failed to document psychotropic medication assessments and non-pharmacological interventions for two residents. One resident with Major Depression and Mild Dementia was prescribed Sertraline and Aripiprazole without documented assessments or interventions. Another resident with Dementia and Major Depressive Disorder was prescribed Fluoxetine, Quetiapine, and Divalproex Sodium, also lacking documentation. The Care Plan Coordinator was unaware of the need for quarterly assessments.
A facility failed to dispose of expired schedule two narcotics for a resident. The policy requires expired medications to be removed and destroyed, but two bottles of Morphine Sulphate with past expiration dates were found in the narcotic box. An LPN confirmed the medications were expired and should have been destroyed.
The facility failed to meet the required minimum floor space per resident bed in 28 rooms, affecting 31 residents. Measurements showed rooms were undersized, with some offering only 73.11 square feet per resident bed. Interviews revealed mixed resident perceptions about room space adequacy. The Regional Director of Operations was aware of the issue.
Inadequate Supervision During Mechanical Lift Transfer Leads to Resident Fall and Nasal Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe use of a mechanical lift during a transfer, resulting in a resident fall with injury. The facility’s mechanical lift policy requires staff to position residents comfortably and safely in the sling and chair, including grasping the top of the sling and, if needed, gently pushing on the resident’s knees while lowering them. The resident involved had an anxiety disorder, a cognitive communication deficit, and severe cognitive impairment, with a care plan addressing communication deficits through allowing extra time, repeating information, not rushing, using one-step directions, and other supportive strategies. The resident’s care plan also documented an actual fall during a mechanical lift transfer to a wheelchair, during which the resident rolled out of the sling onto the floor and was later diagnosed with fractures of both nasal bones, the nasal septum, and a nasal laceration. On the day of the fall, two CNAs conducted the mechanical lift transfer using a sling described by one CNA as a type the resident disliked because its fuzzy material made it easier to slide. Multiple CNAs, including those involved in the incident and others familiar with the resident, reported that the resident frequently leans forward in the sling and requires repeated reminders to sit back. During the incident, one CNA operated the lift controls while the other stood behind the resident, attempting to guide her by holding the sling straps as the resident repeatedly leaned forward. Despite the resident’s continued forward leaning, the CNAs proceeded with lowering her, and she fell forward out of the sling, landing face-first on the leg/foot of the mechanical lift. Staff interviews, including from the CNA supervisor, indicated that CNAs are trained not to rush transfers and not to continue a transfer if a resident is leaning forward or moving unsafely, and that in this case the transfer should not have continued until the resident was in a safe position.
Failure to Protect Resident Dignity Due to Disruptive Behavior
Penalty
Summary
The facility failed to protect the dignity of two residents, R1 and R11, due to the disruptive behavior of another resident, R5. R5, who is moderately cognitively impaired and diagnosed with Depression, Cerebral Palsy, and a Mental Disorder, frequently makes loud, derogatory, and prejudiced comments. These comments have caused discomfort and distress to R1 and R11, both of whom are cognitively intact. R1, diagnosed with Depression, Insomnia, and Obsessive Compulsive Disorder, expressed that R5's comments are bothersome and wishes they would stop. Similarly, R11, diagnosed with Diabetes, reported feeling uncomfortable and often avoids activities to not be subjected to R5's negativity. Despite staff being present and aware of R5's behavior, they have not effectively intervened to stop the comments, as R5 continues to make them. The facility's administrator, V1, was not initially informed of the derogatory remarks but acknowledged the issue upon learning about it and recognized it as a resident rights issue. The administrator emphasized the need for staff to be more vigilant and intervene when necessary to ensure residents' rights to dignity and a comfortable living environment are upheld.
Inadequate Respiratory Care for Resident with COPD
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure, as evidenced by the lack of timely interventions in response to signs of respiratory distress. The resident, identified as R183, exhibited symptoms such as shortness of breath, pale coloring, and the use of accessory muscles for breathing. Despite these symptoms, the resident's oxygen therapy was not adjusted promptly, and the oxygen tubing was found undated and unsanitary, lying on the floor. The resident's oxygen saturation levels were recorded at 88% and 89%, indicating significant respiratory distress, yet the necessary adjustments to the oxygen flow were delayed. The report highlights that the facility's staff, including the Director of Nursing and Licensed Practical Nurses, were aware of the resident's condition but did not take immediate action to alleviate the resident's discomfort or report the changes to a physician in a timely manner. The resident expressed fear and discomfort due to the breathing difficulties, and it was only after a significant delay that the oxygen flow was increased and the decision was made to send the resident to the emergency room. The facility's failure to maintain the oxygen equipment in a sanitary manner and to document the necessary respiratory assessments and interventions contributed to the deficiency in care provided to the resident.
Failure to Document Psychotropic Medication Assessments and Interventions
Penalty
Summary
The facility failed to document psychotropic medication assessments, identify and track targeted behaviors, and attempt non-pharmacological behavioral interventions for two residents. The facility's policy requires that residents receiving antipsychotic drugs undergo gradual dose reduction and behavioral interventions unless clinically contraindicated, with reviews by the interdisciplinary team at least quarterly. However, for one resident with diagnoses of Major Depression and Mild Dementia with Anxiety, there was no documentation of psychotropic assessments, targeted behaviors, or non-pharmacological interventions. This resident was prescribed Sertraline and Aripiprazole. Another resident with Dementia with Agitation and Major Depressive Disorder was also not assessed for psychotropic medication use, with no targeted behaviors identified or tracked, and no non-pharmacological interventions documented. This resident was prescribed Fluoxetine, Quetiapine, and Divalproex Sodium. The Care Plan Coordinator admitted to being unaware of the need for quarterly assessments for residents on psychotropic medications, acknowledging the oversight in documentation and intervention for these residents.
Expired Narcotics Not Disposed
Penalty
Summary
The facility failed to properly dispose of expired schedule two narcotics for one resident, identified as R6, among the three residents reviewed for medications. The facility's policy on Procurement and Storage of Medications requires that all discontinued or expired non-controlled medications be removed from the active medication storage area and either returned to the pharmacy or destroyed as soon as practical. Controlled substances are to be destroyed according to facility policy. However, during an observation, two bottles of Morphine Sulphate were found in the narcotic box of cart two, both with expiration dates that had passed. One bottle contained 13 cubic centimeters of medication, while the other was full with 30 cubic centimeters. A Licensed Practical Nurse acknowledged that the medications were expired and should have been destroyed.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required minimum floor space per resident bed in 28 out of 56 resident rooms, affecting all 31 residents residing in the facility. The deficiency was identified through historical room documentation and onsite measurements conducted with the Maintenance Director. Specifically, rooms 2, 4 through 11, and 14 through 32 were found to be undersized, offering only 73.11 square feet per resident bed in some rooms and 75.65 square feet in others, falling short of the 80 square feet requirement. These rooms are double occupancy and certified for Medicare and Medicaid, with the facility's daily roster confirming their occupancy. Interviews with residents revealed mixed perceptions about the adequacy of room space. Some residents expressed that their rooms were too small for two people, while others felt there was enough space for themselves and a roommate. The Regional Director of Operations acknowledged awareness of the room size issue. Despite some residents being content with their living arrangements, the facility's failure to meet the regulatory space requirements constitutes a deficiency.
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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 Paris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven Of Paris | 1.1 mi | ★★★★★ | 38 | 0 |
| Providence Health Care Center | 13 mi | ★★★★★ | 1 | 0 |
| Pleasant Meadows Senior Living | 13.4 mi | ★★★★★ | 13 | 1 |
| Clinton Gardens | 14.6 mi | ★★★★★ | 10 | 0 |
| Vermillion Convalescent Center | 15.1 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.