Burgaw, NC

The Laurels of Pender

4-star overall rating with 3-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

311 S Campbell Street, Burgaw, NC

(910) 259-6007

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

98

Certified beds

Average residents

89

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ciena Healthcare/Laurel Health Care

Operator or chain grouping

Approved since

1989-03-06

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

84 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 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

0.61

Registered nurse staffing · state 0.59 · national 0.68

LPN hours / resident day

0.92

Licensed practical nurse staffing · state 0.87 · national 0.87

Aide hours / resident day

2.35

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

3.88

All reported nurse hours · state 3.78 · national 3.89

Licensed hours

1.53

RN + LPN hours · state 1.45 · national 1.54

Weekend hours

3.37

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.26

Weekend registered nurse coverage · state 0.38 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

3.78

CMS adjusted total nurse staffing hours

Case-mix index

1.41

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

42%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,533

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

26.41

Composite VBP score used to determine payment impact.

Payment multiplier

0.9842

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.98

Baseline 19.16% · Performance 20.51% · Measure score 1.98 · Achievement 1.98 · Improvement 0

Healthcare-associated infections

1.81

Baseline 5.95% · Performance 7.29% · Measure score 1.81 · Achievement 1.81 · Improvement 0

Total nurse turnover

4.52

Baseline 51.81% · Performance 45.19% · Measure score 4.52 · Achievement 4.52 · Improvement 1.95

Adjusted total nurse staffing

2.25

Baseline 3.12 hours · Performance 3.72 hours · Measure score 2.25 · Achievement 2.25 · Improvement 1.74

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.06%	10.72% 0.7 pts better	No Different than the National Rate · Eligible stays 167 · Observed rate 10.18% · Lower 95% interval 7.43%
Discharge to community	51.03%	50.57% 0.5 pts better	No Different than the National Rate · Eligible stays 150 · Observed rate 44% · Lower 95% interval 42.39%
Medicare spending per beneficiary	1.08	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 104 · Denominator 104
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 104
Discharge self-care score	71.05%	53.69% 17.4 pts better	Numerator 54 · Denominator 76
Discharge mobility score	48.68%	50.94% 2.3 pts worse	Numerator 37 · Denominator 76
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 104 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.29%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 95 · Observed rate 7.37% · Lower 95% interval 4.56%
Staff COVID-19 vaccination coverage	0.87%	8.2% 7.3 pts worse	Numerator 1 · Denominator 115
Staff flu vaccination coverage	7.59%	42% 34.4 pts worse	Numerator 11 · Denominator 145
Discharge function score	52.63%	56.45% 3.8 pts worse	Numerator 40 · Denominator 76
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 67 · Denominator 67
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	15.25%	25.2% 9.9 pts worse	Numerator 9 · Denominator 59

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 1.1 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	1.8 0.8 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	93.4%	91.5% 1.9 pts better	93.4% About the same	Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 94.5% · Q3 89.3% · Q4 94.5% · 4Q avg 93.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.8%	94.1% 4.7 pts better	95.5% 3.3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8%
Percentage of long-stay residents experiencing one or more falls with major injury	1.3%	3.6% 2.3 pts better	3.3% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.4% · Q3 1.3% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.5%	4.8% 3.3 pts better	11.4% 9.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 1.5%
Percentage of long-stay residents who lose too much weight	7.1%	7.2% 0.1 pts better	5.4% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 7.8% · Q3 6.2% · Q4 3.3% · 4Q avg 7.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.0%	21.6% 11.6 pts better	19.6% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 10.8% · Q3 9.2% · Q4 8.1% · 4Q avg 10.0%
Percentage of long-stay residents who received an antipsychotic medication	15.2%	15.0% 0.2 pts worse	16.7% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 16.9% · Q3 14.0% · Q4 11.1% · 4Q avg 15.2% · 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	20.8%	21.5% 0.7 pts better	16.3% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 20.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.2%	16.8% 3.6 pts better	14.9% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 8.5% · Q3 3.4% · Q4 12.7% · 4Q avg 13.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.6% 2.6 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.7%	21.2% 2.5 pts worse	19.8% 3.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 20.6% · Q3 36.1% · Q4 22.8% · 4Q avg 23.7%
Percentage of long-stay residents with pressure ulcers	2.7%	6.0% 3.3 pts better	5.1% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 0.0% · Q3 2.9% · Q4 3.8% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	84.4%	79.9% 4.5 pts better	81.7% 2.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 73.5% · Q2 80.9% · Q3 91.5% · Q4 91.2% · 4Q avg 84.4%
Percentage of short-stay residents who had an outpatient emergency department visit	8.2%	13.2% 5 pts better	12.0% 3.8 pts better	Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.8% · Expected 10.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.2%	1.5% 0.7 pts worse	1.6% 0.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 1.4% · Q4 4.8% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	81.7%	78.1% 3.6 pts better	79.7% 2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 81.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	13.8%	22.9% 9.1 pts better	23.9% 10.1 pts better	Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 13.6% · Expected 23.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2026-01-15 · Fire 2024-09-20

9 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2024-09-20 · Fire 2023-05-04

0 health deficiencies

No concentrated health issue counts in this cycle.

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-05-04 · Fire 2022-01-28

1 health deficiencies

Top issue: Resident Rights (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-09-20

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-12-17

E · Potential for more than minimal harm 2024-09-20

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-12-17

E · Potential for more than minimal harm 2024-09-20

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-09-20

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-12-17

D · Potential for more than minimal harm 2024-09-20

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2024-12-17

F · Potential for more than minimal harm 2023-05-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-08-15

D · Potential for more than minimal harm 2023-05-04

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 2023-08-15

D · Potential for more than minimal harm 2023-05-04

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-08-15

D · Potential for more than minimal harm 2023-05-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-15

D · Potential for more than minimal harm 2023-05-04

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-08-15

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-15

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 2026-02-06

E · Potential for more than minimal harm 2026-01-15

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 2026-02-06