Cycle 1
Health 2024-12-12 · Fire 2024-12-12
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lumberton, NC
Glenflora
5-star overall rating with 5-star inspections with $14,689 in total fines with 2 fire-safety deficiencies in the latest cycle
5701 Fayetteville Road, Lumberton, NC
(910) 739-2821
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lutheran Services Carolinas
Operator or chain grouping
Approved since
1979-06-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 5 staffing / 3 quality stars
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
0.47
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.77
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.44
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.71
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.99
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,901
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0006
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.97
Baseline 21.94% · Performance 19.74% · Measure score 3.97 · Achievement 3.64 · Improvement 3.97
Healthcare-associated infections
4.03
Baseline 6.22% · Performance 6.63% · Measure score 4.03 · Achievement 4.03 · Improvement 0
Total nurse turnover
4.19
Baseline 48.21% · Performance 46.55% · Measure score 4.19 · Achievement 4.19 · Improvement 0.21
Adjusted total nurse staffing
6.63
Baseline 4.20 hours · Performance 4.96 hours · Measure score 6.63 · Achievement 6.63 · Improvement 4.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.07% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 10.26% · Lower 95% interval 7.34% |
| Discharge to community | 64.69% |
50.57%
14.1 pts better
|
Better than the National Rate · Eligible stays 76 · Observed rate 61.84% · Lower 95% interval 53.21% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.1% |
95.27%
2.2 pts worse
|
Numerator 27 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 83.33% |
53.69%
29.6 pts better
|
Numerator 20 · Denominator 24 |
| Discharge mobility score | 75% |
50.94%
24.1 pts better
|
Numerator 18 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 1 · Denominator 29 · Adjusted rate 3.87% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.15% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 86 |
| Staff flu vaccination coverage | 13.14% |
42%
28.9 pts worse
|
Numerator 18 · Denominator 137 |
| Discharge function score | 79.17% |
56.45%
22.7 pts better
|
Numerator 19 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
94.1%
3.5 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.6%
2.6 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.5% · Q3 5.0% · Q4 2.4% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 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 who lose too much weight | 8.7% |
7.2%
1.5 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 16.1% · Q3 6.5% · Q4 6.2% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
21.6%
4.3 pts better
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 16.1% · Q3 16.1% · Q4 18.8% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
15.0%
8.2 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.7% · Q3 3.7% · Q4 6.7% · 4Q avg 6.8% · 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 | 38.3% |
21.5%
16.8 pts worse
|
16.3%
22 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.9% |
16.8%
6.1 pts worse
|
14.9%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 7.7% · Q3 19.2% · Q4 27.6% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.5% |
2.6%
4.9 pts worse
|
1.7%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.0% · Q3 5.0% · Q4 4.9% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
21.2%
1 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 22.6% · Q3 18.8% · Q4 15.3% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
6.0%
1.4 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 9.1% · Q3 2.1% · Q4 9.8% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
79.9%
14.7 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 94.0% · Q3 94.3% · Q4 92.9% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
13.2%
4.2 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 8.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.6% |
78.1%
18.5 pts worse
|
79.7%
20.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.7% |
22.9%
8.2 pts better
|
23.9%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 12.5% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-04-14 · Fire 2022-04-14
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-12
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 2025-02-21
D · Potential for more than minimal harm
2024-12-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-21
F · Potential for more than minimal harm
2023-08-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-09
F · Potential for more than minimal harm
2023-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-09
Inspection history
Recent health citations
J · Immediate jeopardy
2023-12-04
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 2023-11-02
C · Minimal harm
2023-08-24
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-01
D · Potential for more than minimal harm
2022-04-14
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 2022-05-10
D · Potential for more than minimal harm
2022-04-14
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-05-10
Penalties and ownership
What sits behind the stars
$14,689
2023-12-04
Fine
Fine · fine $14,689
Fine
Ownership
Lutheran Services For The Aging, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Glenflora
Operational/Managerial Control · Organization
Goins, Ted
Operational/Managerial Control · Individual
Kropp, Randall
Corporate Director · Individual
Locklear, Austin
Operational/Managerial Control · Individual
Locklear, Charlene
Operational/Managerial Control · Individual
Lsa Management Inc.
Operational/Managerial Control · Organization
Lutheran Services For The Aging, Inc.
Operational/Managerial Control · Organization
Maddry, Karen
Corporate Officer · Individual
Nickerson, Kirby
Corporate Officer · Individual
Smith, Kesha
Operational/Managerial Control · Individual
Smith, Kesha
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Wesley Pines Retirement Community
Lumberton, NC
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Woodhaven Nursing Center
Lumberton, NC
1-star overall rating with 1-star inspections with $128,210 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
The Carrolton of Lumberton
Lumberton, NC
1-star overall rating with 2-star inspections with $37,087 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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