Fayetteville, NC

Carolina Rehab Center of Cumberland

2-star overall rating with 2-star inspections with $97,936 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

4600 Cumberland Road, Fayetteville, NC

(910) 429-1690

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

136

Certified beds

Average residents

132

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Lifeworks Rehab

Operator or chain grouping

Approved since

2000-10-26

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.49

Registered nurse staffing

LPN hours / resident day

1.07

Licensed practical nurse staffing

Aide hours / resident day

1.89

Nurse aide staffing

Weekend hours

3.03

Weekend nurse staffing

RN turnover

61%

Annual RN turnover

Total nurse turnover

61%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	1.8 0.9 pts better	1.9 1 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	0.6	1.8 1.2 pts better	1.8 1.2 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.7%	91.5% 5.2 pts better	93.4% 3.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	92.6%	94.1% 1.5 pts worse	95.5% 2.9 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	0.9%	3.6% 2.7 pts better	3.3% 2.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	9.0%	4.8% 4.2 pts worse	11.4% 2.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	3.4%	7.2% 3.8 pts better	5.4% 2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.6%	21.6% 5 pts better	19.6% 3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	3.8%	15.0% 11.2 pts better	16.7% 12.9 pts better	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened	10.5%	21.5% 11 pts better	16.3% 5.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	8.1%	16.8% 8.7 pts better	14.9% 6.8 pts better	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents with a urinary tract infection	1.2%	2.6% 1.4 pts better	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.3%	21.2% 5.1 pts worse	19.8% 6.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	4.9%	6.0% 1.1 pts better	5.1% 0.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	85.6%	79.9% 5.7 pts better	81.7% 3.9 pts better	Short Stay · 2024Q4-2025Q3
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
Percentage of short-stay residents who newly received an antipsychotic medication	0.4%	1.5% 1.1 pts better	1.6% 1.2 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	71.0%	78.1% 7.1 pts worse	79.7% 8.7 pts worse	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.4%	22.9% 0.5 pts worse	23.9% 0.5 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-02 · Fire 2024-05-03

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2024-05-03 · Fire 2023-02-02

20 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-02-02 · Fire 2021-06-11

2 health deficiencies

Top issue: Quality of Life and Care (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 2024-05-03

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2024-08-15

D · Potential for more than minimal harm 2024-05-03

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 2024-08-15

D · Potential for more than minimal harm 2024-05-03

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-08-15

D · Potential for more than minimal harm 2024-05-03

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-08-15

D · Potential for more than minimal harm 2024-05-03

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-08-15

D · Potential for more than minimal harm 2024-05-03

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 2024-08-15

D · Potential for more than minimal harm 2024-05-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-08-15

F · Potential for more than minimal harm 2023-02-02

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 2023-05-26

F · Potential for more than minimal harm 2023-02-02

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2023-05-26

F · Potential for more than minimal harm 2023-02-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-05-26

D · Potential for more than minimal harm 2023-02-02

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-05-26

D · Potential for more than minimal harm 2023-02-02

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-05-26

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-21

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2026-02-02

E · Potential for more than minimal harm 2025-07-02

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 2025-07-10

G · Actual harm 2025-03-05

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-03-13

J · Immediate jeopardy 2024-11-04

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 2024-08-23

D · Potential for more than minimal harm 2024-11-04

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-11-04

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-11-05

E · Potential for more than minimal harm 2024-10-11

F696 · Quality of Life and Care Deficiencies

Health

Provide appropriate care/assistance for a resident with a prosthesis.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-10-11

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-08-21

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 2024-08-13

G · Actual harm 2024-05-03

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 2024-05-24

G · Actual harm 2024-05-03

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2024-05-24

G · Actual harm 2024-05-03

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-05-24

E · Potential for more than minimal harm 2024-05-03

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-05-24

E · Potential for more than minimal harm 2024-05-03

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-05-24

E · Potential for more than minimal harm 2024-05-03

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-05-24

D · Potential for more than minimal harm 2024-05-03

F551 · Resident Rights Deficiencies

Health

Give the resident's representative the ability to exercise the resident's rights.

Corrected 2024-05-24

D · Potential for more than minimal harm 2024-05-03

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2024-05-24

D · Potential for more than minimal harm 2024-05-03

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-05-24

D · Potential for more than minimal harm 2024-05-03

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-05-24

J · Immediate jeopardy 2024-03-25

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-03-16

G · Actual harm 2024-03-25

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 2024-03-02

D · Potential for more than minimal harm 2024-03-25

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2024-03-16

D · Potential for more than minimal harm 2024-03-25

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-04-03

D · Potential for more than minimal harm 2023-02-02

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2023-02-25

D · Potential for more than minimal harm 2023-02-02

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2023-02-25

Penalties and ownership

What sits behind the stars

$15,015 2025-03-05

Fine

Fine · fine $15,015

Fine

$16,801 2024-10-11

Fine

Fine · fine $16,801

Fine

$49,319 2024-05-03

Fine

Fine · fine $49,319

Fine

$5,850 2024-03-25

Fine

Fine · fine $5,850

Fine

$10,951 2024-03-25

Fine

Fine · fine $10,951

Fine

Ownership

Carolina Cumberland Holdings LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2021-05-28

Charles 1994 Family Grantor Trust