South Hill, VA

Twin Lakes Rehabilitation and Nursing

4-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

125 Buena Vista Circle, South Hill, VA

(434) 447-3151

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

140

Certified beds

Average residents

100

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1987-10-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.45

Registered nurse staffing

LPN hours / resident day

0.78

Licensed practical nurse staffing

Aide hours / resident day

1.70

Nurse aide staffing

Weekend hours

2.31

Weekend nurse staffing

RN turnover

61%

Annual RN turnover

Total nurse turnover

60%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.5 About the same	1.9 0.4 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.4 0.2 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	76.4%	91.2% 14.8 pts worse	93.4% 17 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.5%	94.0% 2.5 pts better	95.5% 1 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	2.5%	3.6% 1.1 pts better	3.3% 0.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	2.5%	15.7% 13.2 pts better	11.4% 8.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	2.2%	5.7% 3.5 pts better	5.4% 3.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.7%	20.2% 13.5 pts better	19.6% 12.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	13.4%	15.0% 1.6 pts better	16.7% 3.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	15.4%	17.5% 2.1 pts better	16.3% 0.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	10.4%	15.7% 5.3 pts better	14.9% 4.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.5% About the same	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	0.9%	1.6% 0.7 pts better	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	16.0%	22.2% 6.2 pts better	19.8% 3.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	6.4%	5.2% 1.2 pts worse	5.1% 1.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	42.2%	74.6% 32.4 pts worse	81.7% 39.5 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	9.5%	11.7% 2.2 pts better	12.0% 2.5 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.6%	1.2% 0.6 pts better	1.6% 1 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	80.6%	73.6% 7 pts better	79.7% 0.9 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.7%	22.0% 2.3 pts better	23.9% 4.2 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-05-03 · Fire 2023-05-03

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2021-06-10 · Fire 2021-06-10

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

4 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 3 Health 2019-05-30 · Fire 2019-05-30

16 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2023-05-03

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-06-27

E · Potential for more than minimal harm 2023-05-03

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-06-27

E · Potential for more than minimal harm 2023-05-03

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-06-27

E · Potential for more than minimal harm 2023-05-03

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-11-28

D · Potential for more than minimal harm 2023-05-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-06-27

D · Potential for more than minimal harm 2023-05-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-11-28

F · Potential for more than minimal harm 2021-06-10

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2021-08-04

E · Potential for more than minimal harm 2021-06-10

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2021-08-04

D · Potential for more than minimal harm 2021-06-10

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2021-08-04

D · Potential for more than minimal harm 2021-06-10

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-08-04

E · Potential for more than minimal harm 2019-05-30

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-08-01

E · Potential for more than minimal harm 2019-05-30

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-08-01

Inspection history

Recent health citations

E · Potential for more than minimal harm 2023-05-03

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F657 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-16

E · Potential for more than minimal harm 2021-06-10

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2021-07-22

E · Potential for more than minimal harm 2021-06-10

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2021-07-22

D · Potential for more than minimal harm 2021-06-10

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2021-07-22

D · Potential for more than minimal harm 2021-06-10

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2021-07-22

D · Potential for more than minimal harm 2021-06-10

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2021-07-22

G · Actual harm 2019-05-30

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2019-07-12

G · Actual harm 2019-05-30

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2019-07-12

G · Actual harm 2019-05-30

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2019-07-12

F · Potential for more than minimal harm 2019-05-30

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2019-07-12

E · Potential for more than minimal harm 2019-05-30

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2019-07-31

E · Potential for more than minimal harm 2019-05-30

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2019-07-12

E · Potential for more than minimal harm 2019-05-30

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2019-07-12

E · Potential for more than minimal harm 2019-05-30

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2019-07-31

D · Potential for more than minimal harm 2019-05-30

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2019-07-12

C · Minimal harm 2019-05-30