01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-19 | 3 | 2026-03-19 | 2 |
| Cycle 2 | 2025-01-09 | 4 | 2025-01-09 | 5 |
| Cycle 3 | 2023-09-15 | 0 | 2023-09-15 | 4 |
CMS CCN 3452352026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Twin Lakes Community
3802 Wade Coble Drive · Burlington, NC 27215 · Alamance County
Certified beds104CMS provider file
Recent citation rows18current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
18 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 1 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-19 · HEALTHF0577Severity C · widespread; potential for minimal harm
Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Correction field: No revisit needed · 2026-03-292026-03-19 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2026-03-292026-03-19 · HEALTHF0638Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Correction field: Deficient, Provider has date of correction · 2026-03-292026-03-19 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has no plan of correction2026-03-19 · FIREK0521Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has no plan of correction2025-03-11 · HEALTHF0604Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Correction field: Deficient, Provider has date of correction · 2025-03-18 · complaint2025-03-11 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2025-03-20 · complaint2025-01-09 · FIREK0311Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Correction field: Deficient, Provider has date of correction · 2025-03-142025-01-09 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-03-142025-01-09 · FIREK0372Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-03-142025-01-09 · FIREK0700Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Correction field: Deficient, Provider has date of correction · 2025-03-142025-01-09 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-03-142024-08-07 · HEALTHF0602Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Past Non-Compliance · 2024-05-03 · complaint2024-08-07 · HEALTHF0603Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Correction field: Past Non-Compliance · 2024-08-01 · complaint2023-09-15 · FIREK0341Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2023-11-202023-09-15 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2023-11-202023-09-15 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2023-11-202023-09-15 · FIREK0923Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2023-11-2003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-08-07 | Fine | $6,152 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LUTHERAN RETIREMENT MINISTRIES OF ALAMANCE COUNTY, NORTH CAROLINAOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 09/30/1983
- FOX, PAMELAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 01/04/2013
- CONKLIN, JONATHANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/01/2017
- FOX, PAMELAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/04/2013
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.32per resident day
RN hours0.73per resident day
Weekend nurse hours4.46per resident day
Staff turnover41.3%CMS reported field
06 / LOCAL RECORDS
Open the Burlington ledger →Other published facilities nearby
Alamance Health Care Center180 beds · CMS overall 1/544 citation rowsEdgewood Place At The Village At Brookwood51 beds · CMS overall 5/513 citation rowsLiberty Commons Nursing & Rehabilitation Center Of122 beds · CMS overall 4/514 citation rowsWhite Oak Manor - Burlington160 beds · CMS overall 2/531 citation rows