Twin Lakes Rehabilitation and Nursing
125 Buena Vista Circle, South Hill, VA 23970 · Mecklenburg County · 140 certified beds · avg 98 residents/day · certified since Oct 14, 1987
Part of chain: EASTERN HEALTHCARE GROUP (18 facilities, chain avg rating 1.5★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 3/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 30, 2019 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 12, 2019 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 30, 2019 · F-0688
The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Why it matters: Without this care, residents can develop stiff, contracted joints and lose the ability to move on their own.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 12, 2019 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 30, 2019 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 12, 2019 (Deficient, Provider has date of correction)
All citations in the current public record (27)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 3, 2023 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 3, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 10, 2021 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Jun 10, 2021 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 10, 2021 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jun 10, 2021 | D · Potential for harm, one-off | The facility did not dispose of garbage and refuse properly. |
| Jun 10, 2021 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 30, 2019 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| May 30, 2019 | ▲ G · Actual harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| May 30, 2019 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| May 30, 2019 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| May 30, 2019 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 30, 2019 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| May 30, 2019 | E · Potential for harm, repeated | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. |
| May 30, 2019 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| May 30, 2019 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 30, 2019 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 30, 2019 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 30, 2019 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| May 30, 2019 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| May 30, 2019 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 30, 2019 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| May 30, 2019 | C · Minimal risk, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 16 | 3 | G ▲ |
| 2021 | 5 | 0 | E |
| 2023 | 6 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Virginia avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.28 | 3.67 | 3.95 | bottom 43% in Virginia; bottom 25% in the U.S. |
| Registered Nurse hours | 0.35 | 0.66 | 0.69 | bottom 17% in Virginia; bottom 16% in the U.S. |
| Weekend total nurse staffing | 2.94 | 3.21 | 3.50 | top 48% in Virginia; bottom 28% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.20 | 0.46 | 0.48 | bottom 18% in Virginia; bottom 11% in the U.S. |
| Total nursing staff turnover (%) | 72.0 | 48.1 | 45.8 | bottom 3% in Virginia; bottom 5% in the U.S. |
| RN turnover (%) | 84.2 | 48.2 | 42.9 | bottom 5% in Virginia; bottom 4% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.10, RN 0.33, weekend 2.78. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| A&j Pomona Enterprises LLC | Organization | 5% or Greater Indirect Ownership Interest | 10% | 04/01/2025 |
| Lyam Eastern Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | 45% | 04/01/2025 |
| Lyam Family Trust | Organization | 5% or Greater Indirect Ownership Interest | 45% | 04/01/2025 |
| VA SNF Operations Holdings 5 LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2025 |
| A&j Pomona Enterprises LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2025 |
| Ackerman, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 07/18/2025 |
| Bankwell Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 04/01/2025 |
| Gittleson, Layla | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/25/2025 |
| Gittleson, Yehuda | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2025 |
| Gittleson, Yehuda | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2025 |
| Gittleson, Yehuda | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2025 |
| Lyam Eastern Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2025 |
| Lyam Family Trust | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2025 |
| Samuels, Shondel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2025 |
| Samuels, Shondel | Individual | ADP of the SNF | NOT APPLICABLE | 07/18/2025 |
| Shapiro, Akiva | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2025 |
| Shapiro, Akiva | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2025 |
| South Hill VA Propco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2025 |
| VA SNF Master Consulting LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2025 |
| VA SNF Master Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/18/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Lawrenceville Health & Rehabilitation | 16.5 mi | Lawrenceville, VA | ★☆☆☆☆ | 2/5 | |
| Wayland Nursing and Rehabilitation Center | 18.4 mi | Keysville, VA | ★★★★☆ | 3/5 | |
| Chase City Health and Rehab Center | 18.7 mi | Chase City, VA | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 495177.