South Hill, VA

Twin Lakes Rehabilitation and Nursing

4-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

125 Buena Vista Circle, South Hill, VA

(434) 447-3151

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

140

Certified beds

Average residents

100

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1987-10-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

0.45

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

0.78

Licensed practical nurse staffing · state 1.00 · national 0.87

Aide hours / resident day

1.70

Nurse aide staffing · state 2.12 · national 2.35

Total nurse hours

2.92

All reported nurse hours · state 3.81 · national 3.89

Licensed hours

1.22

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

2.31

Weekend nurse staffing · state 3.31 · national 3.43

Weekend RN hours

0.12

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.14

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

3.12

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

61%

Annual RN turnover · state 49% · national 45%

Total nurse turnover

60%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,711

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

38.89

Composite VBP score used to determine payment impact.

Payment multiplier

0.9919

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.95% · Performance 21.32% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

6.81

Baseline 7.31% · Performance 5.80% · Measure score 6.81 · Achievement 6.81 · Improvement 6.02

Total nurse turnover

Baseline 69.66% · Performance 49.50% · Measure score 4 · Achievement 3.47 · Improvement 4

Adjusted total nurse staffing

4.74

Baseline 4.38 hours · Performance 4.43 hours · Measure score 4.74 · Achievement 4.74 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.23%	10.72% 1.5 pts better	No Different than the National Rate · Eligible stays 138 · Observed rate 7.25% · Lower 95% interval 6.45%
Discharge to community	71.87%	50.57% 21.3 pts better	Better than the National Rate · Eligible stays 113 · Observed rate 65.49% · Lower 95% interval 63.1%
Medicare spending per beneficiary	0.9	1.02 0.1 pts better
Drug regimen review with follow-up	88.61%	95.27% 6.7 pts worse	Numerator 70 · Denominator 79
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 79
Discharge self-care score	72.88%	53.69% 19.2 pts better	Numerator 43 · Denominator 59
Discharge mobility score	45.76%	50.94% 5.2 pts worse	Numerator 27 · Denominator 59
Pressure ulcers or injuries, new or worsened	5.06%	2.29% 2.8 pts worse	Numerator 4 · Denominator 79 · Adjusted rate 4.64%
Healthcare-associated infections requiring hospitalization	5.8%	7.12% 1.3 pts better	No Different than the National Rate · Eligible stays 89 · Observed rate 3.37% · Lower 95% interval 2.87%
Staff COVID-19 vaccination coverage	6.72%	8.2% 1.5 pts worse	Numerator 8 · Denominator 119
Staff flu vaccination coverage	94.53%	42% 52.5 pts better	Numerator 121 · Denominator 128
Discharge function score	47.46%	56.45% 9 pts worse	Numerator 28 · Denominator 59
Transfer of health information to provider	52.94%	95.95% 43 pts worse	Numerator 27 · Denominator 51
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	44.74%	25.2% 19.5 pts better	Numerator 17 · Denominator 38

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.5 About the same	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.4 0.2 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	76.4%	91.2% 14.8 pts worse	93.4% 17 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 82.5% · Q2 77.1% · Q3 76.8% · Q4 69.1% · 4Q avg 76.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.5%	94.0% 2.5 pts better	95.5% 1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.5%
Percentage of long-stay residents experiencing one or more falls with major injury	2.5%	3.6% 1.1 pts better	3.3% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 2.4% · Q4 4.9% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.5%	15.7% 13.2 pts better	11.4% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 9.0% · 4Q avg 2.5%
Percentage of long-stay residents who lose too much weight	2.2%	5.7% 3.5 pts better	5.4% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.7%	20.2% 13.5 pts better	19.6% 12.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 6.6% · Q3 5.4% · Q4 5.6% · 4Q avg 6.7%
Percentage of long-stay residents who received an antipsychotic medication	13.4%	15.0% 1.6 pts better	16.7% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 13.1% · Q3 10.9% · Q4 14.8% · 4Q avg 13.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	15.4%	17.5% 2.1 pts better	16.3% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 9.4% · Q3 11.3% · Q4 23.5% · 4Q avg 15.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.4%	15.7% 5.3 pts better	14.9% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 13.2% · Q3 5.9% · Q4 13.8% · 4Q avg 10.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.5% About the same	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	1.6% 0.7 pts better	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 1.2% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	16.0%	22.2% 6.2 pts better	19.8% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 6.9% · Q3 17.9% · Q4 25.1% · 4Q avg 16.0%
Percentage of long-stay residents with pressure ulcers	6.4%	5.2% 1.2 pts worse	5.1% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.7% · Q3 9.8% · Q4 4.7% · 4Q avg 6.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	42.2%	74.6% 32.4 pts worse	81.7% 39.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 74.4% · Q2 77.4% · Q3 28.8% · Q4 7.5% · 4Q avg 42.2%
Percentage of short-stay residents who had an outpatient emergency department visit	9.5%	11.7% 2.2 pts better	12.0% 2.5 pts better	Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 10.1% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.6%	1.2% 0.6 pts better	1.6% 1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	80.6%	73.6% 7 pts better	79.7% 0.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 80.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.7%	22.0% 2.3 pts better	23.9% 4.2 pts better	Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 20.3% · Expected 24.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-05-03 · Fire 2023-05-03

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2021-06-10 · Fire 2021-06-10

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

4 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 3 Health 2019-05-30 · Fire 2019-05-30

16 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2023-05-03

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2023-06-27

E · Potential for more than minimal harm 2023-05-03

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-06-27

E · Potential for more than minimal harm 2023-05-03

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-06-27

E · Potential for more than minimal harm 2023-05-03

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-11-28

D · Potential for more than minimal harm 2023-05-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-06-27

D · Potential for more than minimal harm 2023-05-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-11-28

F · Potential for more than minimal harm 2021-06-10

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2021-08-04

E · Potential for more than minimal harm 2021-06-10

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2021-08-04

D · Potential for more than minimal harm 2021-06-10

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2021-08-04

D · Potential for more than minimal harm 2021-06-10

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-08-04

E · Potential for more than minimal harm 2019-05-30

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-08-01

E · Potential for more than minimal harm 2019-05-30

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-08-01

Inspection history

Recent health citations

E · Potential for more than minimal harm 2023-05-03

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-16

E · Potential for more than minimal harm 2021-06-10

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2021-07-22

E · Potential for more than minimal harm 2021-06-10

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2021-07-22

D · Potential for more than minimal harm 2021-06-10

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2021-07-22

D · Potential for more than minimal harm 2021-06-10

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2021-07-22

D · Potential for more than minimal harm 2021-06-10

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2021-07-22

G · Actual harm 2019-05-30

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2019-07-12

G · Actual harm 2019-05-30

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2019-07-12

G · Actual harm 2019-05-30

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2019-07-12

F · Potential for more than minimal harm 2019-05-30

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2019-07-12

E · Potential for more than minimal harm 2019-05-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-07-31

E · Potential for more than minimal harm 2019-05-30

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2019-07-12

E · Potential for more than minimal harm 2019-05-30

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2019-07-12

E · Potential for more than minimal harm 2019-05-30

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2019-07-31

D · Potential for more than minimal harm 2019-05-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2019-07-12

D · Potential for more than minimal harm 2019-05-30

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2019-07-12

C · Minimal harm 2019-05-30