Cycle 1
Health 2025-01-09 · Fire 2025-01-09
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Burlington, NC
Twin Lakes Community
5-star overall rating with 4-star inspections with $6,152 in total fines with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
3802 Wade Coble Drive, Burlington, NC
(336) 538-1400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
95
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-10-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.75
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.46
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.64
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
6.20
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,588
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.51
Composite VBP score used to determine payment impact.
Payment multiplier
1.0105
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.20% · Performance 21.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.89
Baseline 6.15% · Performance 6.67% · Measure score 3.89 · Achievement 3.89 · Improvement 0
Total nurse turnover
9.20
Baseline 43.70% · Performance 26.09% · Measure score 9.20 · Achievement 9.20 · Improvement 8.84
Adjusted total nurse staffing
9.12
Baseline 5.01 hours · Performance 5.67 hours · Measure score 9.12 · Achievement 9.12 · Improvement 8.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.89% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 3.03% · Lower 95% interval 6.18% |
| Discharge to community | 53.18% |
50.57%
2.6 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 53.47% · Lower 95% interval 46.18% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.67% |
95.27%
3.4 pts better
|
Numerator 74 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 52.31% |
53.69%
1.4 pts worse
|
Numerator 34 · Denominator 65 |
| Discharge mobility score | 24.62% |
50.94%
26.3 pts worse
|
Numerator 16 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 5.33% |
2.29%
3 pts worse
|
Numerator 4 · Denominator 75 · Adjusted rate 6.39% |
| Healthcare-associated infections requiring hospitalization | 6.67% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 4.55% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 3.4% |
8.2%
4.8 pts worse
|
Numerator 8 · Denominator 235 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 46.15% |
56.45%
10.3 pts worse
|
Numerator 30 · Denominator 65 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 49 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 12 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
91.5%
2.2 pts better
|
93.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 94.1% · Q3 91.8% · Q4 92.7% · 4Q avg 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
94.1%
2.5 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.6%
0.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.5% · Q3 4.7% · Q4 6.1% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
4.8%
0.4 pts better
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.9% · Q3 3.8% · Q4 6.2% · 4Q avg 4.4% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
7.2%
3.6 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 2.9% · Q4 5.6% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
21.6%
7.9 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 13.7% · Q3 14.1% · Q4 16.7% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.5% |
15.0%
5.5 pts worse
|
16.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 20.3% · Q3 24.1% · Q4 20.0% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 14.8% |
21.5%
6.7 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 14.6% · Q3 17.8% · Q4 11.0% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
16.8%
3.6 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 18.2% · Q3 24.2% · Q4 15.2% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.9%
0.5 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 3.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.6%
0.8 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.2% · Q3 1.2% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
21.2%
3.3 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 28.1% · Q3 23.7% · Q4 21.4% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
6.0%
2.2 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.8% · Q3 2.5% · Q4 6.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
79.9%
14.8 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 96.4% · Q3 97.4% · Q4 94.8% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
13.2%
0.7 pts better
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 10.3% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
78.1%
13.9 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
22.9%
1.1 pts better
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 15.5% · Expected 17.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-15 · Fire 2023-09-15
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-07-21 · Fire 2022-07-21
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-09
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-14
F · Potential for more than minimal harm
2023-09-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-20
D · Potential for more than minimal harm
2022-07-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-07-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-03-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-20
E · Potential for more than minimal harm
2024-08-07
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-08-07
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-08-01
G · Actual harm
2022-07-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-07
F · Potential for more than minimal harm
2022-07-21
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 2022-09-07
D · Potential for more than minimal harm
2022-07-21
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 2022-09-07
D · Potential for more than minimal harm
2022-07-21
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 2022-09-07
D · Potential for more than minimal harm
2022-07-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-09-07
Penalties and ownership
What sits behind the stars
$6,152
2024-08-07
Fine
Fine · fine $6,152
Fine
Ownership
Lutheran Retirement Ministries Of Alamance County, North Carolina
5% Or Greater Direct Ownership Interest · Organization
Conklin, Jonathan
Corporate Officer · Individual
Fox, Pamela
Corporate Officer · Individual
Fox, Pamela
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Liberty Commons Nursing & Rehabilitation Center of
Burlington, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Edgewood Place at the Village at Brookwood
Burlington, NC
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
White Oak Manor - Burlington
Burlington, NC
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $148,522 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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