Twin Lakes Extended Care

Penalties

• Dec 14, 2023 — Fine ($71,455)
• Dec 14, 2023 — Payment Denial · payment denial 4 days
• Dec 14, 2023 — IDPH fine (Nursing Home Care Act) ($2,200)

Inspection findings

1. Feb 6, 2026 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 7, 2026 · CMS health inspection

2. Jun 25, 2024 Fire Safety · 13 findings
   • Not serious Scope/severity F

     E0026 Emergency Preparedness Deficiencies

     Establish roles under a Waiver declared by secretary.

     Corrected Jul 19, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jul 25, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Jul 18, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jul 18, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     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.

     Corrected Jul 18, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Jul 18, 2024 · CMS health inspection

   • Not serious Scope/severity B

     F0912 Environmental Deficiencies

     Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

     Corrected Jul 18, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Aug 9, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 9, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jul 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jul 22, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jul 17, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jul 25, 2024 · CMS fire safety

3. Dec 14, 2023 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jan 10, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jan 10, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Jan 10, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jan 10, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0836 Administration Deficiencies

     Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

     Corrected Jan 10, 2024 · CMS health inspection

   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.3210t) and 300.3240b). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b).

     Statement of deficiencies (PDF)

4. Sep 25, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Oct 5, 2023 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 5, 2023 · CMS health inspection

5. Aug 22, 2023 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Aug 25, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 25, 2023 · CMS health inspection

6. May 18, 2023 Fire Safety · 14 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Jun 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Jun 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0029 Emergency Preparedness Deficiencies

     Develop a communication plan.

     Corrected Jun 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0036 Emergency Preparedness Deficiencies

     Establish emergency prep training and testing.

     Corrected Jun 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected Jun 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jun 10, 2023 · CMS fire safety

   • Not serious Scope/severity C

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected May 31, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 30, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jun 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jun 1, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 1, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0912 Environmental Deficiencies

     Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

     Corrected May 30, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jun 10, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jun 10, 2023 · CMS fire safety

7. May 17, 2022 Health · 11 findings
   • Not serious Scope/severity E

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jun 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jun 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jun 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0700 Quality of Life and Care Deficiencies

     Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

     Corrected Jun 1, 2022 · CMS health inspection

   • Not serious Scope/severity F

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected Jun 1, 2022 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Jun 1, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     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.

     Corrected Jun 1, 2022 · CMS health inspection

   • Not serious Scope/severity E

     F0909 Environmental Deficiencies

     Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

     Corrected Jun 1, 2022 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jun 1, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jun 1, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0913 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure operating rooms are properly protected and written records are maintained and available for inspection.

     Corrected Jun 1, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• DEAN, GENETTIA — adp of the snf, NOT APPLICABLE, since 03/01/2025
• DEAN, GENETTIA — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• ERBLICH, AVRAHAM — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• ERBLICH, AVRAHAM — adp of the snf, NOT APPLICABLE, since 12/01/2024
• FRIEDMAN, BENJAMIN — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• FRIEDMAN, BENJAMIN — adp of the snf, NOT APPLICABLE, since 12/01/2024
• MILLMAN, CHAIM — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• MILLMAN, CHAIM — adp of the snf, NOT APPLICABLE, since 12/01/2024
• MILLMAN, CHAIM — indirect ownership interest, NOT APPLICABLE, since 12/01/2024
• MILLMAN, CHAIM — managing control - governing body, NOT APPLICABLE, since 12/01/2024
• MILLMAN, CHAIM — trustee of the snf, NOT APPLICABLE, since 12/01/2024
• NEWHOUSE, ERIC — indirect ownership interest, NOT APPLICABLE, since 12/01/2024
• NEWHOUSE, ERIC — trustee of the snf, NOT APPLICABLE, since 12/01/2024
• NEWHOUSE, ERIC — managing control - governing body, NOT APPLICABLE, since 12/01/2024
• NEWHOUSE, ERIC — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• NEWHOUSE, TEMI — trustee of the snf, NOT APPLICABLE, since 12/01/2024
• SHEPS, BORUCH — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• SHEPS, BORUCH — adp of the snf, NOT APPLICABLE, since 12/01/2024
• STERN, BEZALEL — direct ownership interest, NOT APPLICABLE, since 12/01/2024
• ZAMAN, ASAD — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• ZAMAN, ASAD — adp of the snf, NOT APPLICABLE, since 12/01/2024
• COM FAMILY TRUST — 5% or greater indirect ownership interest, 12%, since 12/01/2024
• ETN FAMILY HOLDINGS LLC — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• ETN FAMILY HOLDINGS LLC — direct ownership interest, NOT APPLICABLE, since 12/01/2024
• ETN FAMILY HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 02/22/2025
• THE ESTATE OF PETER SCHORR — direct ownership interest, NOT APPLICABLE, since 12/01/2024
• THE ESTATE OF PETER SCHORR — adp of the snf, NOT APPLICABLE, since 12/01/2024
• THE ESTATE OF PETER SCHORR — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• TLCO HOLDINGS LLC — operational/managerial control, NOT APPLICABLE, since 12/01/2024