Home › North Carolina › Alamance County › Twin Lakes Community
Twin Lakes Community
3802 Wade Coble Drive, Burlington, NC 27215 · CMS Certification Number (CCN) 345235
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At a glance
- CMS overall rating
- ★★★★★ 5 of 5
- Health inspection citations
- 7 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 4 from complaints)
- Fire safety citations
- 11
- Fines (last 3 years)
- 1 fine, total $6,152
- Payment denials
- 0
- Most recent standard inspection
- March 19, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★★★★★ 5 of 5 | 2.9 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.9 | 2.8 |
| Staffing | ★★★★★ 5 of 5 | 2.7 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.3 | 3.6 |
| Long-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | March 19, 2026 | 3 | 3 | 0 |
| Cycle 2 | January 9, 2025 | 4 | 0 | 4 |
CMS weighted health inspection score: 15 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
7 health citations across 3 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
March 19, 2026: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2026 |
| D | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2026 |
| C | F-0577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies | Standard | No revisit needed Corrected 03/29/2026 |
March 11, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/20/2025 |
| D | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/18/2025 |
August 7, 2024: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0603 | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Past Non-Compliance Corrected 08/01/2024 |
| E | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Past Non-Compliance Corrected 05/03/2024 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
11 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 03/19/2026 | E | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 08/20/2026 |
| 03/19/2026 | E | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2026 |
| 01/09/2025 | D | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 03/14/2025 |
| 01/09/2025 | D | K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 03/14/2025 |
| 01/09/2025 | D | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/14/2025 |
| 01/09/2025 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/14/2025 |
| 01/09/2025 | D | K-0311 | Have an enclosure around a vertical opening shaft. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/14/2025 |
| 09/15/2023 | D | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 11/20/2023 |
| 09/15/2023 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 11/20/2023 |
| 09/15/2023 | D | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 11/20/2023 |
| 09/15/2023 | D | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/20/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| August 7, 2024 | Fine | $6,152 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 5.32 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.73 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 1.03 | Not published | Not published |
| Nurse aide hours per resident per day | 3.56 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 4.46 | Not published | Not published |
| RN hours per resident per day, weekends | 0.43 | Not published | Not published |
| Total nursing staff turnover (%) | 41.3 | 49 | 45.8 |
| Registered nurse turnover (%) | 31.6 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Lutheran Retirement Ministries of Alamance County, North Carolina
- Ownership type
- Non profit - Corporation
- Chain
- Not published
- Ownership changed in last 12 months
- No
- Certified beds
- 104
- Average residents per day
- 95.8
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- October 4, 1983
- County/parish
- Alamance
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
4 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| LUTHERAN RETIREMENT MINISTRIES OF ALAMANCE COUNTY, NORTH CAROLINA | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| FOX, PAMELA | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CONKLIN, JONATHAN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FOX, PAMELA | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Twin Lakes Community. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.