Twin Lakes Rehabilitation and Nursing
Open-data reference.
Twin Lakes Rehabilitation and Nursing is a non profit - corporation facility in SOUTH HILL, VA with 140 certified beds and a 4-star overall CMS rating. The facility has 27 deficiency records on file.
125 BUENA VISTA CIRCLE, SOUTH HILL, VA 23970
Phone: 4344473151
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 495177
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 140
- Residents
- 100
- In Hospital
- Yes
- County
- Mecklenburg
- Last Inspection
- May 3, 2023
Staffing Data
- RN Hours
- 0.45 (nat'l avg: 0.68)
- LPN Hours
- 0.78
- CNA Hours
- 1.70
- Total Nursing Hours
- 2.92 (nat'l avg: 3.89)
- PT Hours
- 0.14
- Nursing Turnover
- 59.8%
- RN Turnover
- 61.1%
What the CMS Record Reveals About Twin Lakes Rehabilitation and Nursing
Twin Lakes Rehabilitation and Nursing operates 140 certified beds in SOUTH HILL, VA with approximately 100 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (4★), staffing levels (1★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 27 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 2.92 total nursing hours per resident day (national average 3.89), with RN coverage at 0.45 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider embedded within a hospital campus, Twin Lakes Rehabilitation and Nursing falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 59.8%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (27 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 16, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 16, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 16, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 16, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 16, 2023
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 16, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 22, 2021
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 22, 2021
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 22, 2021
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 22, 2021
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 22, 2021
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Jul 12, 2019
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 12, 2019
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 12, 2019
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jul 12, 2019
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 12, 2019
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 12, 2019
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 12, 2019
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 12, 2019
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 12, 2019
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 12, 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.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 12, 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.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 12, 2019
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 12, 2019
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 31, 2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 31, 2019
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 12, 2019
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.2% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.9% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.5% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 76.4% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 42.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.6% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 15.4% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 6.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 96.5% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 80.6% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.4% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 16.0% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 13.4% | Yes |
Penalty History
No penalties on record.
Nearby Nursing Homes in VA
ABINGDON HEALTH CARE LLC
ABINGDON, VA
ALBEMARLE HEALTH & REHABILITATION CENTER
CHARLOTTESVILLE, VA
ALEXANDRIA REHABILITATION AND HEALTHCARE CENTER
ALEXANDRIA, VA
ALLEGHANY HEALTH AND REHAB
CLIFTON FORGE, VA
AMELIA REHABILITATION AND HEALTHCARE CENTER
AMELIA, VA
ANNANDALE HEALTHCARE CENTER
ANNANDALE, VA
Understanding Nursing Home Data
Related Data from Other Sources
Doctors Nearby
Find physicians and specialists in SOUTH HILL, VA on PlainDoctor
Hospitals Nearby
Hospital quality ratings and safety data for SOUTH HILL, VA on PlainHospital
Medicare Plans
Compare Medicare plans and coverage options near SOUTH HILL, VA on PlainMedicare
County Health Data
Health outcomes, access, and quality metrics for Mecklenburg on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for Twin Lakes Rehabilitation and Nursing?
What are the staffing levels at Twin Lakes Rehabilitation and Nursing?
How many beds does Twin Lakes Rehabilitation and Nursing have?
Does Twin Lakes Rehabilitation and Nursing have any deficiencies on record?
Has Twin Lakes Rehabilitation and Nursing received any fines or penalties?
Who owns Twin Lakes Rehabilitation and Nursing?
When was Twin Lakes Rehabilitation and Nursing last inspected?
What quality measures are tracked for Twin Lakes Rehabilitation and Nursing?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.