Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Pender during CMS and state inspections, most recent first.
Surveyors found multiple opened insulin pens and an insulin vial on several medication carts without documented opened dates, despite manufacturer instructions requiring discard after a set number of days once opened. A medication aide on one hall reported that staff were responsible for checking carts for expired medications but stated she did not check insulin dates because she could not administer insulin, while the unit manager confirmed nurses were expected to date insulin pens when opened and identified from pharmacy labels when the pens were received. On another cart, a nurse acknowledged that all nurses were responsible for ensuring insulin products were dated when opened and that the undated Tresiba pen, Lispro vial, and Insulin Glargine pen should have been labeled so staff would know their use-by timeframe. On a skilled care cart, another medication aide similarly stated that all staff should check for expired medications but did not check insulin dates, and the overseeing unit manager admitted she should have verified that all opened insulin pens were dated. The DON stated her expectation that nurses date all insulin pens and vials upon opening so staff can determine if they remain appropriate for use.
Surveyors found that staff failed to properly label, date, and discard opened and expired food items in the kitchen freezers, dry goods storage, and nourishment rooms. Opened bread products in the freezers and dry storage lacked opened and expiration dates, and an opened nectar-consistency nutritional supplement in a nourishment room had no date despite manufacturer instructions for use within a limited time. Disposable food containers labeled with a resident’s name were either missing dates or not discarded within the facility’s stated three-day limit for outside food. The Dietary Manager and Administrator acknowledged expectations that nursing staff label outside food and dietary staff monitor and discard expired items, but these practices were not consistently followed.
A resident admitted with bipolar disorder, dementia, and anxiety was started on multiple psychotropic medications, including an antipsychotic, an anticonvulsant/mood stabilizer, and an antidepressant, which were administered as ordered. The admission MDS showed the resident was cognitively intact and receiving these medications, but review of the electronic record found no completed psychotropic consent form and no documentation that risks versus benefits of the medications had been reviewed with the resident or a representative. The unit manager, NP, and DON all confirmed that the psychotropic consent form should have been completed by the admitting nurse at admission, with a discussion of risks versus benefits prior to medication administration, but this did not occur or was not documented.
A resident with ESRD and a right upper arm A/V fistula, documented by the hospital and facility staff as positive for bruit and thrill but not yet mature, was admitted and later readmitted with a right chest permacath for dialysis. Although the care plan referenced protecting and monitoring the fistula, physician orders and the MAR addressed only the permacath, with no orders to assess the A/V fistula for bruit, thrill, or signs of infection, and no formal restrictions on blood pressures or lab draws in that arm. Multiple nurses, the unit manager, wound nurse, NP, and DON acknowledged the presence of the fistula and indicated that “batch orders” for fistula care should have been initiated on admission, but these orders were never entered, resulting in the fistula not being formally assessed or managed per provider orders.
A resident with orthostatic hypotension was prescribed midodrine with specific blood pressure hold parameters, yet nursing staff and medication aides repeatedly documented administering the drug when systolic blood pressure readings exceeded the ordered threshold. During two consecutive monthly medication regimen reviews, the Consultant Pharmacist reviewed the MARs but documented no new irregularities and did not address these administrations outside the ordered parameters. In interviews, the pharmacist acknowledged that his review process should have identified medications given outside ordered parameters and admitted missing these irregularities, while the DON confirmed that identifying such issues was an expected part of the monthly review.
A resident with hypotension had an order for midodrine 2.5 mg BID with instructions to hold the dose if SBP exceeded 120 mm/Hg or DBP exceeded 80 mm/Hg, but the MAR repeatedly showed the drug as administered despite recorded SBP values above the ordered parameter. Multiple nurses and a medication aide later stated they had either held the medication or not given it, yet documented it as administered on the electronic MAR. The DON reported that medications were expected to be documented accurately and that held medications should be recorded as held with the reason, and confirmed that documentation for this resident’s midodrine was inaccurate.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy when two nurse aides provided incontinence care to a resident with a tracheostomy, gastrostomy tube, and Stage IV sacral pressure ulcer while wearing gloves but not gowns, despite EBP signage and PPE supplies at the room and prior infection control training. The Infection Control Preventionist and DON confirmed that gowns should have been used for this high-contact care under EBP. In addition, the facility did not follow its Tuberculosis Control Plan for a newly admitted resident: although Step 1 of the two-step tuberculin skin test (TST) was completed with a negative result, Step 2 was not administered within the required 1–3 week window and was delayed for several months after an initial documented refusal, without timely re-offer, contrary to facility policy and acknowledged guidelines.
A resident admitted after surgical repair of a left femur fracture had hospital orders for Aquacel dressing and a subsequent physician order for weekly cleansing and silicone foam with silver dressing to the left thigh incision, with a care plan directing wound treatments as ordered and monitoring for infection. Despite these orders, no wound care was documented for nearly two weeks, and the Treatment Administration Record showed one missed treatment without explanation in the progress notes. An RN reported the resident refused care once and never received wound care from her, while the Wound Nurse acknowledged not completing or documenting wound care attempts after reported refusals. A nurse aide stated the resident would often accept care if re-approached. When wound care was finally performed, the original hospital dressing remained in place, and only then was the incision assessed and redressed, contrary to the ordered schedule.
A nursing assistant misappropriated funds from a resident by using the resident's bank account information to create a Cash App account and transferring money to herself and family members. The resident, who had multiple chronic health conditions and was assessed as cognitively intact, denied ever giving permission for these transactions. The misappropriation was discovered by a family member and confirmed through facility investigation and law enforcement, with the nursing assistant ultimately admitting to accepting money in violation of facility policy.
Failure to Date Opened Insulin Pens and Vials on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multi-dose insulin pens and an insulin vial were dated when opened, as required to comply with manufacturer instructions for safe use. During observation of the 400-hall medication cart with a medication aide, surveyors found opened Humalog and Lantus prefilled insulin pens without an opened date, despite manufacturer directions to discard them 28 days after opening. The medication aide stated that nurses and medication aides were responsible for checking medication carts for expired medications but explained that, as a medication aide, she could not administer insulin and did not check dates on insulin products. The unit manager for that hall stated that nurses should be checking the carts to ensure there were no expired medications and that all insulin pens were dated once opened, and she identified from the pharmacy labels that the Lantus and Humalog pens had been received on 01/12/26 and had been used without being dated when opened. On the 100-hall long-term care medication cart, observed with a nurse, surveyors found an opened Tresiba prefilled insulin pen, an opened Lispro insulin vial, and an opened Insulin Glargine prefilled insulin pen, all without opened dates, even though manufacturer instructions required discarding Tresiba 56 days after opening and the Lispro vial and Insulin Glargine pen 28 days after opening. The nurse stated that all nurses were responsible for checking their medication carts for expired medications and ensuring insulin pens and vials were dated when opened, and acknowledged that these insulin products should have had an opened date so staff would know when they should be used by. On the 100-hall skilled care medication cart, observed with another medication aide, an opened Lantus prefilled insulin pen was found without an opened date, despite manufacturer instructions to discard after 28 days once opened. This medication aide stated that all nurses and medication aides were responsible for checking medication carts for expired medications but, as a medication aide who could not administer insulin, she did not check opened dates on insulin pens. The overseeing unit manager stated she should have checked the cart at the start of the shift to ensure all insulin pens were dated once opened. The DON reported that her expectation was that once an insulin pen or vial was opened, nurses should place an opened date on it so they could determine if the medication was still good for use according to manufacturer instructions.
Failure to Label, Date, and Discard Opened and Expired Food Items
Penalty
Summary
Surveyors identified a deficiency related to food storage and labeling practices in the facility’s kitchen, freezers, dry goods storage, and nourishment rooms. During an initial kitchen tour with the Dietary Manager, surveyors observed multiple opened food items in the front kitchen freezer and an outside freestanding freezer, including bread sticks, biscuits, and garlic bread, that lacked any opened dates or expiration dates. In the dry goods storage room, an opened package of hamburger buns and an opened loaf of bread that were no longer in their original packaging were also found without opened dates or expiration dates. The Dietary Manager acknowledged that all opened foods in the freezer and dry goods storage should be labeled with the date opened and the expiration date. Further observations in the nourishment rooms revealed additional labeling and dating failures. In the 400-hall nourishment room, surveyors found an opened container of nectar-consistency nutritional supplement with no opened date or expiration date, despite the manufacturer’s label stating it should be consumed within four days of opening. A disposable food container labeled with a resident’s name but without a date received or expiration date was also present. In the 100-hall nourishment room, a disposable food container with a resident’s name was dated but not discarded after the facility’s stated three-day limit for outside food. The Dietary Manager stated there should not be any expired food in the nourishment rooms, that nursing staff were responsible for labeling outside food with the resident name and date received, and that dietary staff were responsible for monitoring expiration dates and discarding expired food and supplements. The Administrator stated he expected staff to check for expired food and to label and date food stored in the kitchen and nourishment rooms.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to administration for one resident. Resident #98 was admitted with diagnoses including bipolar disorder, dementia, and anxiety, and had physician orders dated 01/07/26 for multiple psychotropic medications: Amitriptyline 25 mg, two tablets in the evening for bipolar disorder; Depakote Sodium ER 500 mg, three tablets in the evening for dementia; and Seroquel 300 mg, one tablet in the evening for dementia. The Medication Administration Record from 01/07/26 through 01/15/26 showed that these medications were administered as ordered during this period. The admission MDS assessment documented that the resident was cognitively intact and received antipsychotic, anticonvulsant, and antidepressant medications during the assessment period. Record review revealed no documentation that Resident #98 or a resident representative had consented to, or had been informed in advance of, the risks versus benefits of receiving Seroquel and Amitriptyline. Unit Manager #2 explained that the admission packet includes a checklist, with item #6 being the psychotropic medication consent form that should be reviewed and signed and is located in the electronic record; upon review of the electronic record, she confirmed there was no documentation of this consent or of a risks-versus-benefits discussion. The Nurse Practitioner stated that the psychotropic consent form should have been completed upon admission and that it was important for the nurse to inform the resident of the risks versus benefits of each psychotropic medication prior to administration. The DON similarly reported that the psychotropic consent form should have been completed by the admitting nurse at admission, with risks versus benefits discussed for each ordered psychotropic medication before the medications were given.
Failure to Obtain and Implement Orders for Assessment of Maturing A/V Fistula in Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement provider orders to assess and manage a maturing right upper extremity arteriovenous (A/V) fistula for a resident with end stage renal disease who was dependent on dialysis. Hospital records dated 12/08/25 documented that the resident had an A/V fistula placed in October 2025 in anticipation of dialysis, which was positive for bruit and thrill but not yet mature, and that a permacath was placed during that hospitalization. On admission and readmission to the facility in December 2025 and January 2026, the resident’s diagnoses included end stage renal disease with dependence on renal dialysis, and the Minimum Data Set reflected that the resident was receiving dialysis services. The care plan dated 12/17/25 identified risk for complications related to dialysis and included interventions such as not drawing blood or taking blood pressure in the arm with the fistula, observing for signs of infection, palpating for thrill, and listening for bruit, with instructions to report abnormalities to the physician. Despite these care plan interventions, the physician orders written on 12/18/25 and again on 01/11/26 addressed only the permacath, specifying dialysis days and monitoring the catheter site for bleeding, infection, and intact caps, with no orders to assess or protect the right arm A/V fistula. Nursing documentation, including skilled care notes and skin assessments, repeatedly acknowledged the presence of the right upper arm A/V fistula and described it as positive for bruit and thrill or as a dialysis access, while also noting the right chest permacath. The Medication Administration Records for December 2025 and January 2026 showed that staff were documenting assessments of the permacath site but contained no orders or documentation for assessment of the A/V fistula site. Interviews with staff confirmed that no orders were initiated for the A/V fistula on either admission. One nurse stated she assessed the A/V fistula and found a positive bruit and thrill but did not enter any orders, explaining that unit managers usually entered “batch orders” for A/V fistulas, which would include assessing bruit and thrill, monitoring for infection, and restricting blood pressures and lab draws in the affected arm. The unit manager, wound treatment nurse, nurse practitioner, and DON each acknowledged awareness of the A/V fistula’s presence, with some staff mistakenly believing it was an old, non-functioning access and others stating that admitting nurses should have initiated batch orders for the maturing fistula. The DON and unit manager confirmed that orders to assess the A/V fistula site were not entered on either admission, despite expectations that such orders should have been in place.
Consultant Pharmacist Failed to Identify Midodrine Dosing Outside Ordered Parameters
Penalty
Summary
A deficiency occurred when the Consultant Pharmacist failed to identify and report a medication irregularity during two consecutive monthly medication regimen reviews for one resident receiving midodrine for orthostatic hypotension. The resident had an order for midodrine 2.5 mg twice daily with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 120 mm/Hg or the diastolic blood pressure exceeded 80 mm/Hg. Review of the November medication administration record (MAR) showed multiple instances where midodrine was documented as administered despite SBP readings above the ordered parameter, including blood pressures of 124/53, 124/68, 129/54, and 129/56 mm/Hg. The Consultant Pharmacist’s November medication regimen review, dated 11/18/25, documented that there were no new irregularities and did not address these administrations outside the ordered parameters. In December, the MAR again showed repeated administrations of midodrine when the resident’s SBP exceeded the ordered hold parameter, with documented blood pressures such as 122/67, 121/66, 132/60, 121/60, 121/67, 122/61, 124/62, 128/61, 131/72, 139/74, 124/69, and 134/68 mm/Hg at the time the medication was signed as given by various nurses and medication aides. The Consultant Pharmacist’s December medication regimen review, dated 12/18/25, again stated there were no new irregularities and did not address the ongoing administration of midodrine outside the specified parameters. In a subsequent interview, the Consultant Pharmacist acknowledged that his monthly review process included checking current and prior MARs for medications given outside ordered parameters, stated that such doses should have been documented as held when outside parameters, and admitted that he should have addressed these irregularities but missed them due to human error. The DON confirmed that the Consultant Pharmacist was expected to identify such issues during the monthly reviews.
Inaccurate MAR Documentation for Parameter-Dependent Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate documentation on the Medication Administration Record (MAR) for a resident receiving midodrine for hypotension. The physician’s order dated 11/6/25 directed that midodrine 2.5 mg be given twice daily and held if the systolic blood pressure (SBP) was over 120 mm/Hg or the diastolic blood pressure was over 80 mm/Hg. The MAR for November, December, and January reflected this order, yet multiple entries showed blood pressure readings above the ordered SBP parameter with the medication still documented as administered. Specific examples included blood pressures of 124/53, 129/54, 132/60, 122/61, 124/62, 134/68, 126/66, and 127/70 mm/Hg, all recorded with midodrine signed out as given. During interviews, the nursing staff and medication aide involved acknowledged that their documentation on the electronic MAR was incorrect. One nurse stated that on 11/15/25 she documented that she administered midodrine when she had not. Another nurse reported that when the resident’s blood pressure was outside the ordered parameters, he held the medication but erroneously documented it as administered on several dates. The medication aide similarly stated that she documented in error that she administered midodrine on two January administrations. The DON stated that her expectation was that medications be administered and documented accurately, and that when a medication is held it should be documented as held with the reason, and acknowledged that the resident’s midodrine was not documented accurately, emphasizing the importance of accurate documentation for evaluation of the resident’s medical condition.
Failure to Follow Enhanced Barrier Precautions and TB Screening Protocols
Penalty
Summary
Surveyors identified that the facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care of a resident with complex medical needs. The resident had a tracheostomy, a gastrostomy tube, and a Stage IV sacral pressure ulcer, and an EBP sign was posted on the room door with a PPE supply bag containing gloves and gowns. During an observation, two nurse aides provided incontinence care to this resident while wearing gloves but did not don gowns, despite the EBP requirements for targeted gown and glove use during high-contact resident care activities. Both aides reported they did not know they were required to wear gowns when providing care to this resident and expressed confusion about PPE use and the purpose of EBP, even though they stated they had received infection control training. The Infection Control Preventionist Nurse confirmed that staff had received infection control training on EBP and were required to complete monthly infection control in-services through an online platform. She stated that the two nurse aides should have worn gowns along with gloves when providing direct care to the resident on EBP. The DON also stated that staff received infection control training and were expected to follow infection control guidelines and wear PPE when providing direct care to residents on EBP. These statements confirmed that the observed care did not comply with the facility’s written EBP policy and expectations for PPE use. Surveyors also found that the facility failed to follow its Tuberculosis (TB) Control Plan for a newly admitted resident. The policy required all first-time residents to receive a two-step tuberculin skin test (TST) on admission, with Step 2 administered 1–3 weeks after Step 1 if the initial reaction was less than 10 mm. The resident received Step 1 with a negative result of 0.1 mm, but Step 2 was not administered within the required 1–3 week timeframe and instead was given several months later. The Infection Control Preventionist Nurse reported that the Medication Administration Record showed the resident refused Step 2 on one date, but acknowledged that staff should have re-offered the test within the required timeframe and that this did not occur. The resident, who was cognitively intact, did not recall refusing the test and stated she would have agreed to complete Step 2 if it had been offered again. The Nurse Practitioner and DON both indicated that the two-step TST guidelines called for Step 2 to be given within 1–3 weeks after Step 1, confirming that the facility did not follow its TB screening policy for this resident.
Failure to Follow Physician Orders for Post-Surgical Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide timely wound care to a resident with a left femur fracture surgically repaired prior to admission. The hospital discharge summary ordered Aquacel dressing to remain in place on the left surgical wound for seven days and then be replaced with new Aquacel. Upon admission, the Wound Nurse entered a physician’s order to cleanse the left lateral thigh wound with wound cleanser, apply a protective barrier to the peri-wound, and cover with a silicone foam with silver dressing every seven days and as needed. The resident’s care plan identified risk for complications from the left thigh surgical wound, with goals for healing without infection and interventions to observe for signs of infection, report abnormalities to the physician, and provide wound treatments as ordered. The MDS admission assessment documented that the resident had moderately impaired cognition, occasional rejection of care, and a surgical wound, but no wound care. From admission through mid-month, there was no documented evidence that wound care was provided to the resident’s left femur surgical wound. The TAR showed that on one date Nurse #6 coded wound care as not performed and directed to see progress notes, but the progress notes contained no explanation for the missed treatment and no documentation of any wound care from admission through that date. In interviews, Nurse #6 stated the resident refused wound care on that date and that she reported the refusal to the Wound Nurse, and also stated she never provided wound care to the resident at any time. The Wound Nurse confirmed that wound care had not been completed because of a reported refusal and that she did not document her own attempt when the resident refused on another day. A nurse aide reported that the resident sometimes refused care but would usually accept it with redirection or re-approach. When wound care was finally observed nearly two weeks after admission, the original hospital dressing dated several days before admission was still in place, and the Wound Nurse then removed it and applied a new silicone foam dressing. The DON and Medical Director both stated that wound care should have been provided according to the physician’s order and sooner than 13 days after admission.
Misappropriation of Resident Funds by Nursing Assistant
Penalty
Summary
A nursing assistant (NA) used a resident's bank account information without permission to create a Cash App account in the resident's name and transferred funds to herself and her family members over several months. The resident, who had multiple chronic medical conditions including chronic respiratory failure, diabetes, heart failure, and hemiplegia, was assessed as cognitively intact on the Minimum Data Set. The misappropriation was discovered when a family member noticed unusual transactions on the resident's bank statement and brought it to the attention of the facility's Business Office Manager (BOM). The transactions, which totaled over $8,000, were linked to the NA through matching names on the Cash App transactions and the NA's personnel file and social media accounts. Upon being confronted, the NA initially denied involvement but later admitted to accepting money from the resident, claiming it was given as gifts or with permission. However, the resident consistently denied ever giving the NA permission to use her bank information or debit card, and stated she was unaware of Cash App until the incident was explained to her. Interviews with law enforcement, the BOM, the former Director of Nursing (DON), and the resident's family corroborated that the NA had accessed the resident's financial information without authorization and used it for personal expenses, including bills and purchases unrelated to the resident's care. The facility's investigation revealed that the NA had violated the facility's policy prohibiting staff from accepting gratuities or gifts from residents. The incident was reported to local law enforcement, Adult Protective Services, and the state regulatory agency. The NA was terminated following the investigation. The resident experienced emotional distress as a result of the theft, expressing anger and hurt over the loss of her money. The case was also investigated by the North Carolina Nursing Assistant Registry, which confirmed the misappropriation of funds.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 15 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Burgaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pender Memorial Hosp Snf | 0.7 mi | — | 0 | 0 |
| Wallace Rehabilitation And Healthcare Center | 12.9 mi | — | 0 | 0 |
| Northchase Nursing And Rehabilitation Center | 17 mi | — | 0 | 0 |
| Woodbury Wellness Center Inc | 18.9 mi | — | 1 | 0 |
| Davis Health And Wellness Center At Cambridge Vill | 19.3 mi | — | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Laurels Of Pender.
100% money-back within 48 hours.
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.