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)
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
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
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 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
0.49
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
2.89
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,677
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.28
Baseline 25.45% · Performance 23.11% · Measure score 2.28 · Achievement 0 · Improvement 2.28
Healthcare-associated infections
2.24
Baseline 9.39% · Performance 8.19% · Measure score 2.24 · Achievement 0 · Improvement 2.24
Total nurse turnover
3.29
Baseline 79.53% · Performance 58.78% · Measure score 3.29 · Achievement 1.20 · Improvement 3.29
Adjusted total nurse staffing
0
Baseline 3.71 hours · Performance 3.06 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.09% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 332 · Observed rate 10.54% · Lower 95% interval 7.66% |
| Discharge to community | 53.22% |
50.57%
2.6 pts better
|
No Different than the National Rate · Eligible stays 385 · Observed rate 44.94% · Lower 95% interval 48.52% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.28% |
95.27%
4 pts better
|
Numerator 277 · Denominator 279 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 279 |
| Discharge self-care score | 52.63% |
53.69%
1.1 pts worse
|
Numerator 90 · Denominator 171 |
| Discharge mobility score | 57.31% |
50.94%
6.4 pts better
|
Numerator 98 · Denominator 171 |
| Pressure ulcers or injuries, new or worsened | 4.66% |
2.29%
2.4 pts worse
|
Numerator 13 · Denominator 279 · Adjusted rate 4.29% |
| Healthcare-associated infections requiring hospitalization | 8.19% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 203 · Observed rate 8.87% · Lower 95% interval 5.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 161 |
| Staff flu vaccination coverage | 27.81% |
42%
14.2 pts worse
|
Numerator 47 · Denominator 169 |
| Discharge function score | 56.14% |
56.45%
0.3 pts worse
|
Numerator 96 · Denominator 171 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 180 · Denominator 180 |
| Transfer of health information to patient | 98.28% |
96.28%
2 pts better
|
Numerator 57 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 30.46% |
25.2%
5.3 pts better
|
Numerator 46 · Denominator 151 |
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 · Adjusted 0.9 · Observed 1.1 · Expected 2.3 · Used in QM five-star |
| 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 · Adjusted 0.6 · Observed 0.7 · Expected 1.8 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 98.8% · Q3 96.4% · Q4 91.2% · 4Q avg 96.7% |
| 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 · 4Q avg 92.6% |
| 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 · Q1 1.1% · Q2 0.0% · Q3 1.2% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| 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 · Q1 13.0% · Q2 5.3% · Q3 6.4% · Q4 11.6% · 4Q avg 9.0% |
| 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 · Q1 1.2% · Q2 1.3% · Q3 3.8% · Q4 8.0% · 4Q avg 3.4% |
| 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 · Q1 20.0% · Q2 17.5% · Q3 14.5% · Q4 14.1% · 4Q avg 16.6% |
| 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 · Q1 4.8% · Q2 3.7% · Q3 3.2% · Q4 3.5% · 4Q avg 3.8% · 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 | 10.5% |
21.5%
11 pts better
|
16.3%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% · Used in QM five-star |
| 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 · Q1 14.3% · Q2 11.4% · Q3 2.8% · Q4 3.0% · 4Q avg 8.1% · 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 | 1.2% |
2.6%
1.4 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.2% · Q4 2.6% · 4Q avg 1.2% · Used in QM five-star |
| 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 · Q1 28.3% · Q2 30.9% · Q3 17.6% · Q4 28.5% · 4Q avg 26.3% |
| 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 · Q1 7.0% · Q2 5.1% · Q3 4.8% · Q4 2.4% · 4Q avg 4.9% · Used in QM five-star |
| 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 · Q1 87.4% · Q2 88.1% · Q3 86.8% · Q4 80.5% · 4Q avg 85.6% |
| 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 8.7% · Expected 10.8% · Used in QM five-star |
| 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 · Q1 0.9% · Q2 0.4% · Q3 0.0% · Q4 0.4% · 4Q avg 0.4% · Used in QM five-star |
| 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 · 4Q avg 71.0% |
| 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 · Adjusted 23.4% · Observed 25.0% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
Charles 1994 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Ck 2008 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Drm South LLC
5% Or Greater Indirect Ownership Interest · Organization
Edward 1998 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Lauren 2020 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Lauren 2020 LLC
5% Or Greater Indirect Ownership Interest · Organization
Leps 2003 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Maher, Cindy
W-2 Managing Employee · Individual
Norman 5571 & Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Norman 5571 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Norman 5571 LLC
5% Or Greater Indirect Ownership Interest · Organization
Rl 2008 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Robin 2008 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Robin 2008 LLC
5% Or Greater Indirect Ownership Interest · Organization
Rsbrm South Manager LLC
Operational/Managerial Control · Organization
Saul 2012 Family Grantor Trust
5% Or Greater Indirect Ownership Interest · Organization
Springrock South LLC
5% Or Greater Indirect Ownership Interest · Organization
Summer South LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
The Carrolton of Fayetteville
Fayetteville, NC
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Village Green Health and Rehabilitation
Fayetteville, NC
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Autumn Care of Fayetteville
Fayetteville, NC
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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