SeniorHomeViolations
B-
73/100

Twin Lakes Rehabilitation and Nursing Inspection Report, Violations & Safety Grade (SOUTH HILL, Virginia)

125 BUENA VISTA CIRCLE, SOUTH HILL, Virginia 23970

Phone: 4344473151

CMS Overall:3/5

Overview & Bed Count

Certified Beds
140
Avg Residents/Day
95.1
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Mecklenburg
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health4/5
Staffing1/5
Quality3/5

Nurse Staffing Check

MetricThis FacilityVirginia AvgDifference
RN Hours per Resident per Day0.270.71-0.44
Total Nurse Hours per Resident per Day3.223.88-0.66
CMS Staffing Rating1/52.5/5-
Nursing Staff Turnover60.4%47.5%-

Health Citation History

27 health citations on record

DateCategoryDescriptionSeverity
2023-05-03Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.E – Moderate Harm Potential
2023-05-03Freedom from Abuse, Neglect, and Exploitation DeficienciesDevelop and implement policies and procedures to prevent abuse, neglect, and theft.D – Moderate Harm Potential
2023-05-03Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2023-05-03Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.D – Moderate Harm Potential
2023-05-03Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2023-05-03Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2021-06-10Nursing and Physician Services DeficienciesProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.E – Moderate Harm Potential
2021-06-10Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2021-06-10Resident Assessment and Care Planning DeficienciesCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedD – Moderate Harm Potential
2021-06-10Nutrition and Dietary DeficienciesDispose of garbage and refuse properly.D – Moderate Harm Potential
2021-06-10Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D – Moderate Harm Potential
2019-05-30Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.G – Actual Harm
2019-05-30Quality of Life and Care DeficienciesProvide 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.G – Actual Harm
2019-05-30Quality of Life and Care DeficienciesProvide enough food/fluids to maintain a resident's health.G – Actual Harm
2019-05-30Infection Control DeficienciesImplement a program that monitors antibiotic use.F – Moderate Harm Potential
2019-05-30Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.E – Moderate Harm Potential
2019-05-30Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.E – Moderate Harm Potential
2019-05-30Quality of Life and Care DeficienciesProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.E – Moderate Harm Potential
2019-05-30Nursing and Physician Services DeficienciesProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.E – Moderate Harm Potential
2019-05-30Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.D – Moderate Harm Potential
2019-05-30Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2019-05-30Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2019-05-30Quality of Life and Care DeficienciesProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.D – Moderate Harm Potential
2019-05-30Pharmacy Service DeficienciesEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.D – Moderate Harm Potential
2019-05-30Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D – Moderate Harm Potential
2019-05-30Nursing and Physician Services DeficienciesPost nurse staffing information every day.C – Minimal Harm Potential
2019-05-30Infection Control DeficienciesProvide and implement an infection prevention and control program.C – Minimal Harm Potential

Fire Safety Citation History

12 fire safety citations on record

DateCategoryDescriptionSeverity
2023-05-03Egress DeficienciesAdd 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.E – Moderate Harm Potential
2023-05-03Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.E – Moderate Harm Potential
2023-05-03Services DeficienciesHave elevators that firefighters can control in the event of a fire.E – Moderate Harm Potential
2023-05-03Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.E – Moderate Harm Potential
2023-05-03Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.D – Moderate Harm Potential
2023-05-03Smoke DeficienciesInstall corridor and hallway doors that block smoke.D – Moderate Harm Potential
2021-06-10Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.F – Moderate Harm Potential
2021-06-10Egress DeficienciesHave properly located and lighted "Exit" signs.E – Moderate Harm Potential
2021-06-10Services DeficienciesHave properly installed electrical wiring and gas equipment.D – Moderate Harm Potential
2021-06-10Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.D – Moderate Harm Potential
2019-05-30Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2019-05-30Services DeficienciesHave properly installed electrical wiring and gas equipment.E – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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