Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Lakes during CMS and state inspections, most recent first.
The facility failed to ensure CNAs received required 90-day performance evaluations. Personnel file review showed two CNAs had no 90-day evals, and the Regional HR Manager confirmed the missing evaluations. The facility policy stated HR was responsible for maintaining accurate personnel files, including performance evaluations.
Improper Food Storage in Kitchen Refrigerator and Freezer: Surveyors observed undated pre-cooked meatloaf and sausage patties in the walk-in refrigerator, along with multiple items in the walk-in freezer that were undated, expired, unsealed, or open to air, including raw cookie dough, cooked ham, frozen lasagna, hamburger patties, and catfish filets. The DM confirmed the items were improperly stored and that some should be discarded. Facility policy required TCS foods and leftovers to be labeled, covered, and dated.
The facility failed to ensure PASARR screening was completed accurately for a resident with cerebral infarction, vascular dementia, DM2, AFib, and HTN. After a diagnosis of psychotic disorder with hallucinations was added to the chart, the facility did not complete a new PASARR to reflect the change, and a later PASARR still indicated no SMI. The SSD verified the PASARR did not accurately identify the resident’s psychotic disorder diagnosis.
Unsecured Hazardous Chemicals in Satellite Kitchens: Hazardous cleaning products, including spray cleaners, bleach germicidal spray, Sani Wipes, and Oxivir wipes, were found in unlocked cabinets and a drawer in two kitchenette areas on the skilled nursing unit. An LPN, RN, Administrator, and CNA confirmed the items were accessible to residents and should have been secured, while MSDS sheets identified flammable, corrosive, and irritating ingredients.
Expired Humalog insulin was found in medication carts for two residents with diabetes. An open vial for one resident and an insulin pen for another were both dated beyond the 28-day expiration period, and LPNs confirmed the insulin should have been discarded. The DON verified the 28-day expiration rule, and pharmacy guidance and facility policy required opened insulin to be labeled and outdated medications removed from use.
A resident with Alzheimer's and other conditions was inappropriately administered Risperidone for a non-approved diagnosis of dementia with psychotic disturbance. The DON confirmed the medication was given without a clinically indicated diagnosis, contrary to the prescribing information.
Missing 90-Day CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants received 90-day performance evaluations. Review of personnel files showed CNA #500 was hired on 08/18/25 and had no 90-day evaluation, and CNA #505 was hired on 11/24/25 and also had no 90-day evaluation. During an interview on 05/27/26 at 4:00 P.M., the Regional Human Resource Manager confirmed that CNAs #500 and #505 did not receive 90-day evaluations. Review of the facility policy titled Personnel File Maintenance and Records Retention showed the Human Resources Department was responsible for maintaining accurate personnel files for each associate in accordance with applicable federal, state, and local regulations, and that personnel files would include performance evaluations.
Improper Food Storage in Kitchen Refrigerator and Freezer
Penalty
Summary
The facility failed to properly store foods in a safe and sanitary manner in the main kitchen walk-in refrigerator and freezer. During observation with the Dietary Manager, the walk-in refrigerator contained a pan of pre-cooked meatloaf and an opened box of sausage patties, both undated. In the walk-in freezer, surveyors observed a bag of raw cookie dough that was undated and open to air, a bag of cooked ham with a discard date of 12/22/25, an opened pan of frozen lasagna with a discard date of 05/04/26, an undated bag of frozen hamburger patties open to air, and a container of catfish filets that was unsealed and open to air. The Dietary Manager confirmed the meatloaf and sausage patties were undated and should be discarded, and also confirmed the freezer contained opened and undated items, expired items, and items left open to air. Facility policy stated that all time and temperature control safety foods, including leftovers, should be labeled, covered, and dated when stored in the refrigerator.
PASARR Screening Not Updated for New Psychotic Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that preadmission screening and resident review (PASARR) screenings were completed accurately for one resident. The resident was admitted with diagnoses including cerebral infarction, vascular dementia, diabetes mellitus type 2, atrial fibrillation, and hypertension, and later had severe cognitive impairment and dependence on staff for activities of daily living documented on the MDS. The medical record also showed that a diagnosis of psychotic disorder with hallucinations was added to the chart after admission, but the facility did not complete a new PASARR when that diagnosis was added. A prior PASARR completed by the hospital at admission showed no indications of serious mental illness, and a later PASARR completed by the prior Social Services Director again indicated no SMI. During interview, the Social Services Director verified that the facility failed to complete a new PASARR that accurately identified the resident’s diagnosis of psychotic disorder with hallucinations, which is designated as a serious mental illness.
Unsecured Hazardous Chemicals in Satellite Kitchens
Penalty
Summary
The facility failed to properly store potentially hazardous chemicals in two satellite kitchens on the skilled nursing unit. During observation of the community kitchenette on [NAME] Court, a spray bottle of Kontrol Morning Fresh was found in an open cabinet under the sink, and the LPN confirmed it was in an unlocked cabinet and easily accessible to residents. The product label identified it as flammable and capable of causing skin irritation, and the MSDS stated it contained hazardous ingredients and was to be kept out of the reach of children. A second observation of the same unit found a bottle of Clorox bleach germicidal spray and a bottle of Glance glass and multi-purpose cleaner in an unlocked cabinet under the sink, which the RN confirmed was easily accessible to residents. In addition, two containers of Sani Wipes were observed in open cabinets just outside the kitchenette, and the Administrator confirmed they were unsecured and should be secured. A spray bottle of multipurpose cleaner and a cannister of Oxivir wipes were also found in an unlocked drawer, and the CNA confirmed the cleaning agents were not supposed to be in the kitchenette. The MSDS sheets for these products described hazardous, corrosive, flammable, and irritating ingredients and noted storage and handling precautions.
Expired Insulin Left in Medication Carts
Penalty
Summary
The facility failed to ensure insulin vials and pens were properly labeled and stored for two residents with diabetes. Resident #49 had an order for Humalog insulin four units subcutaneously with breakfast and six units with dinner, and staff administered six doses from the MAR. During observation of the nursing unit-A medication cart, an open vial of insulin for Resident #49 was found dated past the 28-day expiration period, and an LPN confirmed it was expired and should have been discarded. Resident #8 had diagnoses of diabetes mellitus type one and type two and an order for Humalog insulin 10 units subcutaneously three times daily with meals. Review of the MAR showed 17 doses were administered, and observation of the medication cart found a Humalog insulin pen dated as opened past the 28-day expiration period. An LPN verified the insulin was expired and should have been discarded. The DON confirmed Humalog insulin expires 28 days after removal from refrigerated storage and placement on the medication cart, and the pharmacy guidelines and facility medication storage policy stated insulin should be labeled with the open date and outdated medications removed from use.
Inappropriate Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident did not receive antipsychotic medication without an approved indication and usage. Resident #21, who was admitted with diagnoses including Alzheimer's disease with early onset, anxiety disorder, hypertension, insomnia, unspecified psychosis, and unspecified mood disorder, was prescribed Risperidone. The medication was ordered for a diagnosis of dementia with psychotic disturbance, which is not a clinically indicated diagnosis for Risperidone according to the prescribing information provided by the facility's pharmacy. The Minimum Data Set (MDS) comprehensive assessment indicated that Resident #21 had moderate cognitive impairment and required varying levels of assistance with daily activities. Despite this, the resident was administered Risperidone, an antipsychotic medication, for a diagnosis that is not approved for its use. The Director of Nursing confirmed that the medication was being administered for an inappropriate diagnosis, highlighting a failure in adhering to proper medication administration protocols.
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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 Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montgomery Care Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Blue Ash Health & Rehab | 1.3 mi | ★★★★★ | 5 | 0 |
| Meadowbrook Care Center | 1.6 mi | ★★★★★ | 10 | 0 |
| Courtyard At Seasons | 1.8 mi | ★★★★★ | 0 | 0 |
| Kenwood Terrace Healthcare Center | 2 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.