Twin Lakes Rehabilitation and NursingCMS ratings, inspections and fines
- Address
- 125 Buena Vista Circle, South Hill, VA 23970
- CCN
- 495177
- Ownership type
- Non-profit, corporation
- Certified beds
- 140
- Residents per day
- 98
- CMS flags
- No standard survey in more than 2 years
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives Twin Lakes Rehabilitation and Nursing an overall rating of 3 of 5 stars. The last standard survey was on 3 May 2023. The latest survey cycle has 6 health citations. The median for nursing homes in Virginia is 11. CMS lists no fines for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Mecklenburg County median | Virginia median | US average (CMS) |
|---|---|---|---|---|
| Overall rating | 3 | 4.0 | 3.0 | 3.0 |
| Health inspection rating | 4 | 4.0 | 3.0 | 2.8 |
| Staffing rating | 1 | 2.0 | 2.0 | 2.9 |
| Quality measure rating | 3 | 5.0 | 4.0 | 3.6 |
A median is the middle value of the homes in the group: 3 homes in the county, 289 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Virginia median |
|---|---|---|---|
| Cycle 1 (latest) | 3 May 2023 | 6 | 11 |
| Cycle 2 | 10 Jun 2021 | 5 | 10 |
| Cycle 3 | No date | 16 | 10 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | J0 | K0 | L0 |
| Actual harm that is not immediate jeopardy | H0 | I0 | |
| No actual harm, potential for more than minimal harm | |||
| No actual harm, potential for minimal harm | A0 | B0 |
Survey cycle 1 (latest): 6 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 3 May 2023 | F0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Standard survey | 16 Jun 2023 |
| 3 May 2023 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard survey | 16 Jun 2023 |
| 3 May 2023 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Standard survey | 16 Jun 2023 |
| 3 May 2023 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard survey | 16 Jun 2023 |
| 3 May 2023 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard survey | 16 Jun 2023 |
| 3 May 2023 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 16 Jun 2023 |
Survey cycle 2: 5 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 10 Jun 2021 | F0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard survey | 22 Jul 2021 |
| 10 Jun 2021 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Standard survey | 22 Jul 2021 |
| 10 Jun 2021 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard survey | 22 Jul 2021 |
| 10 Jun 2021 | F0814 | Dispose of garbage and refuse properly. | D | Standard survey | 22 Jul 2021 |
| 10 Jun 2021 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard survey | 22 Jul 2021 |
Survey cycle 3: 16 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 30 May 2019 | F0641 | Ensure each resident receives an accurate assessment. | D | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard survey | 31 Jul 2019 |
| 30 May 2019 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Standard survey | 31 Jul 2019 |
| 30 May 2019 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0688 | 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. | G | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | E | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | E | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0692 | Provide enough food/fluids to maintain a resident's health. | G | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0732 | Post nurse staffing information every day. | C | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0880 | Provide and implement an infection prevention and control program. | C | Standard survey | 12 Jul 2019 |
| 30 May 2019 | F0881 | Implement a program that monitors antibiotic use. | F | Standard survey | 12 Jul 2019 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
CMS lists no fine and no payment denial for this home in its penalties file.
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Virginia median | Virginia average (CMS) |
|---|---|---|---|
| All nurse staff | 3.10 | 3.40 | 3.76 |
| Registered nurses (RN) | 0.33 | 0.50 | 0.69 |
| Licensed practical nurses (LPN) | 0.90 | 1.00 | |
| Nurse aides | 1.87 | 2.07 | |
| All nurse staff, weekends | 2.78 | 3.00 | 3.29 |
- Nurse staff turnover in a year
- 72.0%
- Nurse staff turnover, Virginia median
- 48.3%
- RN turnover in a year
- 84.2%
- Administrators who left in a year
- 2
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Virginia median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.3% | 13.3% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.5% | 0.2% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.6% | 1.1% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.5% | 3.4% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.9% | 1.0% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 12.9% | 14.2% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 8.0% | 4.2% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 14.2% | 13.3% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- Non-profit, corporation
- Setting
- In a hospital
- Legal business name
- South Hill VA Opco LLC
- Chain
- Eastern Healthcare Group (18 homes in the CMS chain file)
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| VA SNF Operations Holdings 5 LLC | 5% or greater direct ownership interest | 100% | 1 Apr 2025 |
| A&J Pomona Enterprises LLC | 5% or greater indirect ownership interest | 10% | 1 Apr 2025 |
| Lyam Eastern Holdco LLC | 5% or greater indirect ownership interest | 45% | 1 Apr 2025 |
| Bankwell Bank | 5% or greater security interest | 1 Apr 2025 | |
| VA SNF Master Consulting LLC | Operational/managerial control | 1 Apr 2025 | |
| A&J Pomona Enterprises LLC | Adp of the snf | 1 Apr 2025 | |
| Lyam Eastern Holdco LLC | Adp of the snf | 1 Apr 2025 | |
| South Hill VA Propco LLC | Adp of the snf | 1 Apr 2025 | |
| VA SNF Master Consulting LLC | Adp of the snf | 18 Jul 2025 | |
| VA SNF Realty Holdings 5 LLC | Adp of the snf | 1 Apr 2025 | |
| Ydi Eastern Holdco LLC | Adp of the snf | 1 Apr 2025 |
The site shows organisations only. It does not show the names of persons.
Other homes in Mecklenburg County
| Nursing home | City | Overall rating | Citations, latest cycle | Fines | Last standard survey | |
|---|---|---|---|---|---|---|
| Chase City Health and Rehab Center | Chase City | 5 of 5 | 1 | $0 | 16 Feb 2023 | |
| Clarksville Health & Rehab Center | Clarksville | 4 of 5 | 9 | $22,874 | 30 Nov 2022 |
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Virginia Department of Health: file a complaintThe complaint page of the State Survey Agency for Virginia, from the CMS list of agencies.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of Twin Lakes Rehabilitation and Nursing (CCN 495177). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/twin-lakes-rehabilitation-and-nursing-south-hill-va-495177/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was Twin Lakes Rehabilitation and Nursing last inspected?
- The latest inspection with a citation in the CMS record was on 3 May 2023. It was a standard survey. It gave 6 citations. The standard survey before the last one was on 10 Jun 2021. CMS marks the last health inspection of this home as more than 2 years old.
- Who operates Twin Lakes Rehabilitation and Nursing?
- The CMS record gives the ownership type as non-profit, corporation. CMS lists the home in the chain Eastern Healthcare Group. The CMS ownership file names VA SNF Master Consulting LLC for operational or managerial control. This site does not show the names of persons.
- Is Twin Lakes Rehabilitation and Nursing a Special Focus Facility?
- No. The CMS provider file lists no Special Focus status for this home. CMS lists 1 home in Virginia as a Special Focus Facility and 5 as candidates.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.