Twin Lakes Rehabilitation and Nursing
125 Buena Vista Circle, South Hill, VA 23970
Twin Lakes Rehabilitation and Nursing is a nursing home in South Hill, Virginia. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating3 of 5
- Last standard health inspectionMay 3, 2023 (3 years ago)
- Health citations since May 30, 201927 (Virginia average 39)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of June 24, 2026
Name
CMS lists a new legal business name for this home.
CMS update of May 27, 2026
Ownership
CMS lists this home under a new chain.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
CMS update of December 15, 2025
Name
CMS lists a new legal business name for this home.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 5 of 5 to 2 of 5.
Name
CMS lists a new name for this home. It was COMMUNITY MEMORIAL HOSPITAL HUNDLEY CENTER.
Staffing
Total nurse staffing reported to CMS went from 4.0 to 3.0 hours per resident per day.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Staffing
Total nurse staffing reported to CMS went from 4.4 to 3.3 hours per resident per day.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Health inspection on May 3, 2023
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 16, 2023.
CMS has cited this home for F0684 2 times since 2019.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on June 16, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on June 16, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 16, 2023.
CMS has cited this home for F0686 2 times since 2019.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on June 16, 2023.
CMS has cited this home for F0695 2 times since 2019.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 16, 2023.
CMS has cited this home for F0880 2 times since 2019.
Fire safety inspection on May 3, 2023
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Add 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.
CMS lists it as corrected on June 27, 2023.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on June 27, 2023.
Citation K0531. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have elevators that firefighters can control in the event of a fire.
CMS lists it as corrected on June 27, 2023.
Citation K0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on November 28, 2023.
CMS has cited this home for K0761 2 times since 2021.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 27, 2023.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on November 28, 2023.
CMS has cited this home for K0363 2 times since 2019.
Health inspection on June 10, 2021
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on July 22, 2021.
CMS has cited this home for F0725 2 times since 2019.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 22, 2021.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on July 22, 2021.
Citation F0814. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on July 22, 2021.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on July 22, 2021.
CMS has cited this home for F0842 2 times since 2019.
Fire safety inspection on June 10, 2021
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on August 4, 2021.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on August 4, 2021.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on August 4, 2021.
CMS has cited this home for K0511 2 times since 2019.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on August 4, 2021.
Health inspection on May 30, 2019
16 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
21 of 289 Virginia homes (7%) got a citation at the actual harm level in 2019.
Show the 16 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 12, 2019.
Citation F0688. Severity G: actual harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 12, 2019.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on July 12, 2019.
Citation F0881. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on July 12, 2019.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 31, 2019.
Citation F0690. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 12, 2019.
Citation F0691. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS lists it as corrected on July 12, 2019.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on July 12, 2019.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on July 12, 2019.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 31, 2019.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on July 12, 2019.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on July 12, 2019.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on July 12, 2019.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on July 12, 2019.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on July 12, 2019.
Citation F0880. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 12, 2019.
Fire safety inspection on May 30, 2019
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on August 1, 2019.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on August 1, 2019.
CMS star ratings
- 3 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (434) 447-3151
- Last standard health inspection
- May 3, 2023 (3 years ago)
- Certified beds
- 140
- Residents per day, on average
- 95.1
- Ownership type
- Non profit - Corporation
- Legal business name
- South Hill VA Opco LLC
- Chain
- Eastern Healthcare Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Virginia average (27 vs 39).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- VA SNF OPERATIONS HOLDINGS 5 LLC5% or greater direct ownership interest · 100% · since 04/01/2025
- A&J POMONA ENTERPRISES LLC5% or greater indirect ownership interest · 10% · since 04/01/2025
- LYAM EASTERN HOLDCO LLC5% or greater indirect ownership interest · 45% · since 04/01/2025
- LYAM FAMILY TRUST5% or greater indirect ownership interest · 45% · since 04/01/2025
- VA SNF MASTER CONSULTING LLCOperational/managerial control · not applicable · since 04/01/2025
Show 1 more
- GITTLESON, YEHUDAOperational/managerial control · not applicable · since 04/01/2025
Questions
When was Twin Lakes Rehabilitation and Nursing last inspected?
CMS lists May 3, 2023 as the date of its most recent standard health inspection.
How many citations (violations) does Twin Lakes Rehabilitation and Nursing have?
CMS lists 27 health citations since May 30, 2019. CMS also calls these deficiencies.
Has Twin Lakes Rehabilitation and Nursing been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Twin Lakes Rehabilitation and Nursing?
Its CMS overall star rating is 3 of 5.
Is Twin Lakes Rehabilitation and Nursing a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.