Cycle 1
Health 2025-08-29 · Fire 2024-09-12
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lumberton, NC
Woodhaven Nursing Center
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
1150 Pine Run Drive, Lumberton, NC
(910) 671-5703
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
115
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1969-05-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
35 facilities
Chain averages 3 overall / 3 health / 2 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
0.26
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.14
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
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,720
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 41.05% · Performance 67.86% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.12
Baseline 5.32 hours · Performance 3.97 hours · Measure score 3.12 · Achievement 3.12 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.87% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 7.64% |
| Discharge to community | 56.09% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 51.92% · Lower 95% interval 45.94% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 83.05% |
95.27%
12.2 pts worse
|
Numerator 49 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 21 · Denominator 36 |
| Discharge mobility score | 52.78% |
50.94%
1.8 pts better
|
Numerator 19 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 5.08% |
2.29%
2.8 pts worse
|
Numerator 3 · Denominator 59 · Adjusted rate 4.52% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 125 |
| Staff flu vaccination coverage | 15.22% |
42%
26.8 pts worse
|
Numerator 28 · Denominator 184 |
| Discharge function score | 72.22% |
56.45%
15.8 pts better
|
Numerator 26 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.0 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.8 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
91.5%
6.6 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 99.0% · Q3 98.9% · Q4 98.9% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
94.1%
3 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 1.5% |
4.8%
3.3 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.2% · Q3 1.2% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
7.2%
0.3 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.2% · Q3 11.4% · Q4 6.4% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
21.6%
0.1 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 20.8% · Q3 25.3% · Q4 20.3% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
15.0%
0.7 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 14.9% · Q3 13.0% · Q4 15.5% · 4Q avg 14.3% · 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 | 23.1% |
21.5%
1.6 pts worse
|
16.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 26.1% · Q3 12.0% · Q4 30.7% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.5% |
16.8%
4.7 pts worse
|
14.9%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 25.8% · Q3 20.0% · Q4 17.2% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
0.9%
2.5 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.6% · Q3 4.3% · Q4 2.5% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.6% |
2.6%
2 pts worse
|
1.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.1% · Q3 6.4% · Q4 5.4% · 4Q avg 4.6% · 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 28.4% · Q2 24.6% · Q3 26.7% · Q4 15.1% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
6.0%
5.4 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 11.0% · Q3 10.9% · Q4 10.7% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
79.9%
9.3 pts better
|
81.7%
7.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.2% · Q2 92.4% · Q3 95.1% · Q4 91.7% · 4Q avg 89.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
13.2%
2.5 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 15.6% · Expected 11.1% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
78.1%
9.4 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
22.9%
5.1 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 24.4% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2023-05-18
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-05-18 · Fire 2022-01-24
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-09-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-09-12
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 2024-11-30
D · Potential for more than minimal harm
2024-09-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-30
F · Potential for more than minimal harm
2023-05-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-05-18
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 2023-07-31
F · Potential for more than minimal harm
2023-05-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-05-18
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-05-18
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 2023-07-31
F · Potential for more than minimal harm
2023-05-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-05-18
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 2023-07-31
D · Potential for more than minimal harm
2023-05-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-05-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-31
F · Potential for more than minimal harm
2022-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-14
E · Potential for more than minimal harm
2022-01-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-14
E · Potential for more than minimal harm
2022-01-24
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 2022-03-14
D · Potential for more than minimal harm
2022-01-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-03-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-08-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-08-29
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 2025-10-01
D · Potential for more than minimal harm
2025-08-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-08-29
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 2025-10-01
D · Potential for more than minimal harm
2025-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-01
C · Minimal harm
2025-08-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-01
E · Potential for more than minimal harm
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-09-12
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 2024-09-19
D · Potential for more than minimal harm
2024-09-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-09-19
K · Immediate jeopardy
2024-07-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-12
J · Immediate jeopardy
2024-07-31
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 2024-09-12
J · Immediate jeopardy
2024-07-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-05-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-04-24
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-04-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-31
G · Actual harm
2023-12-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-11
G · Actual harm
2023-12-15
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-01-11
E · Potential for more than minimal harm
2023-05-18
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-18
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-05-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-23
B · Minimal harm
2023-05-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
$94,175
2024-07-31
Fine
Fine · fine $94,175
Fine
$0
2024-07-31
Payment Denial
Payment Denial · denial start 2024-08-24 · 26 days
26 day denial
$9,718
2024-04-24
Fine
Fine · fine $9,718
Fine
$24,317
2023-12-15
Fine
Fine · fine $24,317
Fine
Ownership
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Calcutt, Joeseph V
Corporate Director · Individual
John A Mcneill Jr 2012 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Kling, Ashley
Operational/Managerial Control · Individual
Liberty Commons Of Robeson County, LLC
5% Or Greater Indirect Ownership Interest · Organization
Liberty Real Properties Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Liberty Real Properties Vii LLC
5% Or Greater Indirect Ownership Interest · Organization
Mcneill, John
Limited Partnership Interest · Individual
Mcneill, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Ronald B And Cynthia J Mcneill 2013 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Wilson, Jeffrey
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
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
#3
Harborview Lumberton
Lumberton, NC
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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