Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Lakes Community during CMS and state inspections, most recent first.
The facility failed to complete required quarterly MDS assessments within 14 days of the ARD for multiple residents. Record review showed that several residents had quarterly MDS assessments initiated and marked as "in progress" but not finalized by the regulatory deadline. Two MDS coordinators, who share responsibility for transmitting MDS assessments, acknowledged the incomplete status and attributed delays in part to a transition in job duties. The DON and the Administrator were aware that some MDS assessments were behind or past due and stated that their expectation was for MDS assessments to be completed on time.
The facility failed to complete required annual MDS assessments within 14 days of the ARD for two residents. Record review showed that each resident had an annual MDS with an ARD that remained in progress and was not completed. Two MDS Coordinators, who shared responsibility for transmitting MDS assessments, acknowledged the assessments were incomplete due to transitioning from previous job duties. In interviews, the DON and the Administrator both stated they were aware that some MDS assessments were behind or past due, while also stating their expectation that MDS assessments be completed timely to meet federal regulations.
Survey results were not clearly posted or easily identifiable in the lobby, and residents reported not knowing where to find them. During a Resident Council meeting, multiple residents stated they were unaware of the survey results’ location, and one recalled that only a sign about passing the survey had been posted in the past. Observations of the reception area showed no visible survey results or signage directing residents or visitors, and the survey binder was kept on a high countertop, partially hidden by decorations and without clear labeling on the visible side. The receptionist and administrator indicated that residents and visitors had to ask for the binder and that information about survey results was printed on the binder cover and discussed during Resident Council meetings.
A resident with vascular dementia exhibited combative behavior during care, leading a nurse aide to hold the resident's hands to prevent being hit, which was deemed a physical restraint. The facility's investigation found no evidence of abuse, but the nurse aide was dismissed for violating policy. The resident's responsible party and the facility doctor did not observe any signs of abuse.
A resident was allegedly physically restrained and hit by a nurse aide during incontinence care, witnessed by another aide who failed to report the incident immediately. The delay in reporting by the witnessing aide and subsequent delay by the nurse due to a personal emergency resulted in a breach of the facility's abuse policy, which requires immediate reporting to leadership.
A resident's oxycodone medication and controlled medication count sheet were misappropriated by a nurse, as confirmed by camera footage. The facility's Pyxis system provided emergency doses, ensuring the resident did not miss any medication. The nurse was terminated, and the incident was reported to authorities.
A resident with severe cognitive impairment was found trapped in a bathroom, unable to move her wheelchair, after a nurse aide, not assigned to her, took her into her room and closed the door. The aide refused the resident's request to be taken elsewhere, leading to her involuntary seclusion. Video footage and staff interviews confirmed the aide's actions, resulting in his termination.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for 10 of 24 residents reviewed. Record review showed that multiple residents had quarterly MDS assessments with established ARDs that remained in an “in progress” status and were not completed. Specifically, residents identified in the report had quarterly MDS assessments with ARDs ranging from mid-January through late February that were not finalized within the required timeframe. Each cited resident’s quarterly assessment was initiated and assigned an ARD, but the documentation showed the assessments were left incomplete beyond the regulatory deadline. During interviews, two MDS Coordinators stated they were both responsible for transmitting MDS assessments and acknowledged that the cited assessments were incomplete. One MDS Coordinator explained that the assessments were not finished due to transitioning from previous job duties. In a separate interview, the DON and the Administrator each acknowledged awareness that some MDS assessments were behind or past due, and both stated their expectation that MDS assessments be completed timely to meet federal regulations. The report does not provide additional clinical details or medical histories for the affected residents beyond their admission dates and the status of their quarterly MDS assessments.
Failure to Complete Annual MDS Assessments Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete required annual Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for two residents. Record review showed that one resident, admitted on an unspecified date, had an annual MDS with an ARD of 2/6/26 that remained in progress and was not completed. Another resident, also admitted on an unspecified date, had an annual MDS with an ARD of 1/28/26 that likewise remained in progress and was not completed. During interviews, two MDS Coordinators stated they were both responsible for transmitting MDS assessments and acknowledged that the assessments for these residents were incomplete, attributing this to transitioning from previous job duties. In a separate interview, the DON and the Administrator each acknowledged awareness that some MDS assessments were behind or past due, while stating their expectation that MDS assessments be completed timely to meet federal regulations. These findings demonstrate that the facility did not assess residents completely in a timely manner upon admission and periodically at least every 12 months, as required, because the annual MDS assessments for the two residents were not completed within the regulatory timeframe following the ARD.
Survey Results Not Clearly Posted or Identifiable in Lobby
Penalty
Summary
The deficiency involves the facility’s failure to make survey results easily accessible and visible to residents and visitors in the main lobby. During a Resident Council meeting attended by eight residents, participants reported they did not know where the survey results were located. One resident stated that in the past the facility had posted a sign indicating they had passed the survey. Subsequent observation of the receptionist desk and adjacent sitting area in the main lobby showed that no survey results were accessible and no signage was visible to direct residents or visitors to the survey results. On a later observation and interview at the receptionist desk, there was still no visible signage indicating the location of the survey results. The receptionist stated that residents and visitors needed to ask for the survey book and pointed to a white binder on the reception desk countertop, which was approximately four feet from the floor and partially obscured by foliage and decorations, with no visible identification on the cover. When turned over, the binder cover indicated it contained information including results of compliance surveys and that similar notebooks were in each neighborhood. The administrator stated that survey results were kept at the receptionist desk and in each neighborhood, that the signage was printed on the front of the binder, and that residents were told survey results during Resident Council meetings.
Resident's Right to Be Free from Physical Restraint Violated
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraint when a nurse aide held a resident's hands during incontinent care. The resident, who had been diagnosed with vascular dementia with behavioral disturbances, exhibited combative behavior during care. The nurse aide, in response to being hit by the resident, held the resident's hands to prevent further hitting. This action was considered a form of physical restraint, which is against the facility's policy. The incident was reported by another nurse aide who witnessed the event and later informed a nurse. The nurse aide who held the resident's hands stated that she did so to prevent being hit and did not consider it as restraining the resident. However, the facility's investigation could not substantiate the allegation of abuse, as there were no visible injuries or signs of distress on the resident. Despite this, the nurse aide was dismissed for violating the facility's policy on restraining residents. The facility's investigation involved interviews with staff and the resident's responsible party, as well as an assessment by the facility doctor, who found no evidence of abuse. The responsible party and the doctor both noted that the resident could be challenging to care for but did not observe any signs of abuse. The facility's draft plan of correction was noted to be missing information on new effective interventions to protect the resident from further abuse.
Failure to Report and Address Abuse Allegation
Penalty
Summary
The facility failed to adhere to its abuse policy and procedures concerning the identification, protection, and reporting of abuse for a resident who was physically restrained. During an incident involving incontinence care, a nurse aide (NA #1) was observed by another aide (NA #2) holding a resident's hands and allegedly hitting the resident in the chest. NA #2 did not intervene or report the incident immediately to the nursing or administrative staff, which was a breach of the facility's policy requiring immediate reporting of abuse allegations. The incident was eventually reported by NA #2 to Nurse #1 at the end of the shift the following day, who then delayed reporting to the Director of Nursing (DON) due to a personal emergency. This delay in reporting resulted in a lack of immediate protection for the resident and potentially other residents. The facility's policy mandates that staff must report abuse allegations immediately to leadership, and the failure to do so was a significant deficiency in the facility's procedures.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, specifically controlled medications. A resident, who was cognitively intact, had an order for oxycodone to manage severe pain. However, the medication and its controlled medication count sheet went missing from the medication cart. The facility became aware of the issue when the resident requested pain medication, and it was discovered that the oxycodone was not available in the cart. An investigation revealed that Nurse #1 was responsible for the removal of the medication card containing 30 tablets of oxycodone and the controlled medication count sheet. This was substantiated by reviewing camera footage, which showed Nurse #1 removing items from the medication cart during her shift. Despite interviews with nursing staff, including Nurse #1, no one admitted to removing the controlled medication sheet. The facility confirmed that the medication had been delivered and signed off by Nurse #1 and Nurse #5. The resident did not miss any doses of pain medication due to the facility's Pyxis backup system, which provided emergency doses of oxycodone. The resident was assessed immediately after the incident, with no adverse consequences noted. The facility took immediate action by terminating Nurse #1 and reporting the incident to relevant authorities, including the Department of Health and Human Services, law enforcement, and the North Carolina Board of Nursing.
Involuntary Seclusion of Resident by Unassigned Nurse Aide
Penalty
Summary
The facility failed to protect a resident's rights to be free from involuntary seclusion. The incident involved a resident with severe cognitive impairment due to vascular dementia, among other diagnoses, who was found trapped in a bathroom with her wheelchair wedged on the lip of the shower. The resident was unable to move or exit the bathroom independently. This situation was discovered by therapy staff who overheard the resident yelling in an unusual tone and subsequently found her in a compromised position. The investigation revealed that a nurse aide, who was not assigned to the resident, had taken her into her room and closed the door, leaving her unable to leave the room. Video footage showed the nurse aide interacting with the resident and refusing her request to be taken to another location, instead pushing her back into her room. The nurse aide was observed leaving the room and closing the door, although there was no visual confirmation of the bathroom door being closed or the resident's position in the room. Interviews with staff and review of video footage indicated that the nurse aide had previously been on the resident's unit without assignment and had been involved in a similar incident. Despite the resident's ability to propel herself in a wheelchair, the facility determined that the nurse aide's actions constituted involuntary seclusion, as the resident was left in a position where she could not free herself without assistance.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Liberty Commons Nursing & Rehabilitation Center Of | 1.3 mi | ★★★★★ | 2 | 0 |
| Edgewood Place At The Village At Brookwood | 3.5 mi | ★★★★★ | 0 | 0 |
| White Oak Manor - Burlington | 6 mi | ★★★★★ | 3 | 0 |
| Peak Resources - Alamance, Inc | 6.7 mi | ★★★★★ | 4 | 0 |
| Alamance Health Care Center | 6.9 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.