CCN 495177

Twin Lakes Rehabilitation and Nursing

125 BUENA VISTA CIRCLE, South Hill, VA 23970 · Mecklenburg County

Phone: (434) 447-3151
Ownership: Non profit - Corporation
Certified beds: 140
Residents per day: 97.8
Health citations: 27
Penalties: 0
Fines: 0 · $0
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 4 · short-stay 3.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

CMS indicates the most recent health inspection was more than two years before this file was processed.

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 1.87; 2.07; 2.32
LPN/LVN: 0.90; 1.00; 0.86
Registered nurse: 0.33; 0.69; 0.69
Total nurse staff: 3.10; 3.76; 3.86
Weekend total: 2.78; 3.29; 3.42
Weekend RN: 0.20; 0.46; 0.48

Adjusted total nurse hours: 3.28. Adjusted RN hours: 0.35. Case-mix total: 3.62. Case-mix index: 1.325.

Total nursing staff turnover: 72.0%. RN turnover: 84.2%. Administrators who left: 2.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 0 fines totaling $0, and 0 payment denials.

The Penalties file has no individual penalty rows for this CCN.

Cycle 1 standard survey: May 3, 2023. Health deficiencies counted in cycle 1: 6. Cycle 1 total health score: 28.

Cycle 2 standard survey: June 10, 2021. Cycle 2/3 health deficiencies: 5. Total weighted health survey score: 28.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 27 citations for this home, including 0 at immediate jeopardy and 3 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

May 3, 2023

6 citations

Tag	What CMS cited	Scope and severity	Status
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 16, 2023
F607	Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 16, 2023
F657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 16, 2023
F686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 16, 2023
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 16, 2023
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 16, 2023

June 10, 2021

5 citations

Tag	What CMS cited	Scope and severity	Status
F725	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 22, 2021
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 22, 2021
F655	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 22, 2021
F814	Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 22, 2021
F842	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 22, 2021

May 30, 2019

16 citations

Tag	What CMS cited	Scope and severity	Status
F686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · July 12, 2019
F688	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. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · July 12, 2019
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · July 12, 2019
F881	Implement a program that monitors antibiotic use. Infection Control Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 31, 2019
F690	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F691	Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F725	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F656	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 31, 2019
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F744	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F756	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F842	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F732	Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3	C: widespread, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · July 12, 2019
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 3	C: widespread, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · July 12, 2019

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
CMS indicates the provider is located in a hospital.
Chain name in the file: Eastern Healthcare Group (18 facilities). Chain average overall rating: 1.5.
Legal business name: South Hill VA Opco LLC.
First approved for Medicare and Medicaid services: October 14, 1987.
Resident and family council: Resident.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for Twin Lakes Rehabilitation and Nursing?

Twin Lakes Rehabilitation and Nursing has an overall rating of 3 out of 5. The health inspection rating is 4, staffing is 1, and the quality measure rating is 3.

How many health citations does CMS list for Twin Lakes Rehabilitation and Nursing?

The Health Deficiencies file lists 27 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 3 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for Twin Lakes Rehabilitation and Nursing?

CMS reports 3.10 total nurse hours per resident per day, including 0.33 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

May 30, 2019

16 citations

Tag	What CMS cited	Scope and severity	Status
F686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · July 12, 2019
F688	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. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · July 12, 2019
F692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · July 12, 2019
F881	Implement a program that monitors antibiotic use. Infection Control Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 31, 2019
F690	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F691	Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F725	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F656	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 31, 2019
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F744	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F756	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F842	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 12, 2019
F732	Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Standard survey · Cycle 3	C: widespread, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · July 12, 2019
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 3	C: widespread, no actual harm, with potential for minimal harm	Deficient, Provider has date of correction · July 12, 2019