The Vardell Report.Twin Lakes Rehabilitation and Nursing

Across 3 inspections from May 2019 to May 2023, state surveyors documented 27 findings at Twin Lakes Rehabilitation and Nursing; 27 have a recorded correction; CMS lists no enforcement action in the window.

Inspections

3

2019–2023, standard

Findings

27

Deficiencies cited by state inspectors

Corrected

27

Of 27 findings, with a recorded correction date

Penalties

0

No fines or payment denials in the window

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. May 32023

   Standard health inspection

   6 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jun 16, 2023
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Jun 16, 2023
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 16, 2023
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 16, 2023
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 16, 2023
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 16, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jun 102021

   Standard health inspection

   5 findings

   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jul 22, 2021
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jul 22, 2021
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Jul 22, 2021
   • F814Dispose of garbage and refuse properly.Level DNo actual harm, potential for moreCorrected Jul 22, 2021
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 22, 2021

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. May 302019

   Standard health inspection

   16 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jul 12, 2019
   • F688Provide 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.Level GActual harmCorrected Jul 12, 2019
   • F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Jul 12, 2019
   • F881Implement a program that monitors antibiotic use.Level FNo actual harm, potential for moreCorrected Jul 12, 2019
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jul 31, 2019
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Jul 12, 2019
   • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Jul 12, 2019
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jul 12, 2019
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 12, 2019
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jul 31, 2019
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jul 12, 2019
   • F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Jul 12, 2019
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jul 12, 2019
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Jul 12, 2019
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Jul 12, 2019
   • F880Provide and implement an infection prevention and control program.Level CPotential for minimal harmCorrected Jul 12, 2019

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Quality of Care, Cited in Two Inspections

   Inspectors cited F684 in May 2019 and May 2023. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192123F684 across all 3 inspections, oldest to newest
2. 2

   Pressure Injury Care, Cited in Two Inspections

   Inspectors cited F686 in May 2019 and May 2023. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192123F686 across all 3 inspections, oldest to newest
3. 3

   Respiratory Care, Cited in Two Inspections

   Inspectors cited F695 in May 2019 and May 2023. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192123F695 across all 3 inspections, oldest to newest
4. 4

   Nursing Staff Levels, Cited in Two Inspections

   Inspectors cited F725 in May 2019 and June 2021. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192123F725 across all 3 inspections, oldest to newest
5. 5

   Medical Records, Cited in Two Inspections

   Inspectors cited F842 in May 2019 and June 2021. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192123F842 across all 3 inspections, oldest to newest
6. 6

   Infection Control, Cited in Two Inspections

   Inspectors cited F880 in May 2019 and May 2023. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192123F880 across all 3 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in two inspections, most seriously at level E.

2. 02

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in two inspections, most seriously at level G.

3. 03

   Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

   Respiratory Care: cited in two inspections, most seriously at level D.

4. 04

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   Nursing Staff Levels: cited in two inspections, most seriously at level E.

5. 05

   How can a family request a resident’s records, and how are they kept accurate?

   Medical Records: cited in two inspections, most seriously at level D.

6. 06

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in two inspections, most seriously at level D.

7. 07

   Has the home been fined or had payments denied before this record begins?

   CMS lists no fines or payment denials in this window. The record starts May 30, 2019; anything earlier is not in it.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Virginia state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection May 30, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Jun 10, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection May 3, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 495177

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.