Twin Lakes Rehabilitation and Nursing
125 Buena Vista Circle · South Hill, VA · 23970 · 4344473151
140 certified beds Non profit - Corporation Chain: Eastern Healthcare Group Hospital-based
Why this verdict
- 3 citations involved actual harm to residents.
- No federal fines or payment denials in CMS’s 3-year window.
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Red flags
Total nurse staffing below 3.0 hours per resident-day
2.97 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
68% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 4 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 2.97 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.37 | 0.55–0.75 |
| Weekend hours / resident-day | 2.71 | ≈ weekday level |
| Nursing turnover / year | 68% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (27 in the current record)
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Potential for harm · D May 3, 2023
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected June 16, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 3, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected June 16, 2023 · Resident Assessment and Care Planning
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Potential for harm · E May 3, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 16, 2023 · Quality of Life and Care
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Potential for harm · D May 3, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected June 16, 2023 · Quality of Life and Care
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Potential for harm · D May 3, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Corrected June 16, 2023 · Quality of Life and Care
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Potential for harm · D May 3, 2023
Provide and implement an infection prevention and control program.
Corrected June 16, 2023 · Infection Control
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Potential for harm · D June 10, 2021
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected July 22, 2021 · Resident Assessment and Care Planning
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Potential for harm · E June 10, 2021
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected July 22, 2021 · Nursing and Physician Services
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Potential for harm · E June 10, 2021
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected July 22, 2021 · Nutrition and Dietary
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Potential for harm · D June 10, 2021
Dispose of garbage and refuse properly.
Corrected July 22, 2021 · Nutrition and Dietary
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Potential for harm · D June 10, 2021
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected July 22, 2021 · Resident Assessment and Care Planning
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Actual harm · G May 30, 2019
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 12, 2019 · Quality of Life and Care
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Actual harm · G May 30, 2019
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 July 12, 2019 · Quality of Life and Care
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Actual harm · G May 30, 2019
Provide enough food/fluids to maintain a resident's health.
Corrected July 12, 2019 · Quality of Life and Care
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Potential for harm · D May 30, 2019
Ensure each resident receives an accurate assessment.
Corrected July 12, 2019 · Resident Assessment and Care Planning
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Potential for harm · D May 30, 2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 31, 2019 · Resident Assessment and Care Planning
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Potential for harm · E May 30, 2019
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 31, 2019 · Quality of Life and Care
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Potential for harm · E May 30, 2019
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 July 12, 2019 · Quality of Life and Care
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Potential for harm · E May 30, 2019
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected July 12, 2019 · Quality of Life and Care
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Potential for harm · D May 30, 2019
Provide safe and appropriate respiratory care for a resident when needed.
Corrected July 12, 2019 · Quality of Life and Care
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Potential for harm · E May 30, 2019
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected July 12, 2019 · Nursing and Physician Services
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Potential for harm · D May 30, 2019
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected July 12, 2019 · Quality of Life and Care
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Potential for harm · D May 30, 2019
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected July 12, 2019 · Pharmacy Service
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Potential for harm · D May 30, 2019
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected July 12, 2019 · Resident Assessment and Care Planning
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Potential for harm · F May 30, 2019
Implement a program that monitors antibiotic use.
Corrected July 12, 2019 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 495177 · certified since October 14, 1987. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.