Fayetteville, NC

Woodlands Nursing & Rehabilitation Center

4-star overall rating with 4-star inspections with $4,709 in total fines with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

400 Pelt Drive, Fayetteville, NC

(910) 822-0515

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

80

Certified beds

Average residents

75

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Liberty Senior Living

Operator or chain grouping

Approved since

1997-02-27

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

0.36

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

2.71

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

3.99

All reported nurse hours · state 3.78 · national 3.89

Licensed hours

1.28

RN + LPN hours · state 1.45 · national 1.54

Weekend hours

3.71

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.18

Weekend registered nurse coverage · state 0.38 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.38

CMS adjusted RN staffing hours

Adjusted total hours

4.19

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

57%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,565

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

Performance score

19.92

Composite VBP score used to determine payment impact.

Payment multiplier

0.9823

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

0.95

Baseline 59.04% · Performance 59.81% · Measure score 0.95 · Achievement 0.95 · Improvement 0

Adjusted total nurse staffing

3.04

Baseline 4.14 hours · Performance 3.94 hours · Measure score 3.04 · Achievement 3.04 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.7%	10.72% About the same	No Different than the National Rate · Eligible stays 38 · Observed rate 13.16% · Lower 95% interval 7.21%
Discharge to community	44.57%	50.57% 6 pts worse	No Different than the National Rate · Eligible stays 40 · Observed rate 32.5% · Lower 95% interval 31.18%
Medicare spending per beneficiary	1.02	1.02 About the same
Drug regimen review with follow-up	93.88%	95.27% 1.4 pts worse	Numerator 46 · Denominator 49
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 49
Discharge self-care score	34.62%	53.69% 19.1 pts worse	Numerator 9 · Denominator 26
Discharge mobility score	30.77%	50.94% 20.2 pts worse	Numerator 8 · Denominator 26
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 49 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	7.08%	8.2% 1.1 pts worse	Numerator 8 · Denominator 113
Staff flu vaccination coverage	26.96%	42% 15 pts worse	Numerator 31 · Denominator 115
Discharge function score	34.62%	56.45% 21.8 pts worse	Numerator 9 · Denominator 26
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 21 · Denominator 21
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	12.9%	25.2% 12.3 pts worse	Numerator 4 · Denominator 31

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.4	1.8 0.6 pts worse	1.9 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.0 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	1.8 0.3 pts better	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	92.1%	91.5% 0.6 pts better	93.4% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 90.2% · Q3 92.1% · Q4 90.2% · 4Q avg 92.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.6%	94.1% 4.5 pts better	95.5% 3.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury	2.4%	3.6% 1.2 pts better	3.3% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 1.6% · Q4 4.9% · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.3%	4.8% 2.5 pts better	11.4% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.0% · Q3 1.8% · Q4 0.0% · 4Q avg 2.3%
Percentage of long-stay residents who lose too much weight	5.7%	7.2% 1.5 pts better	5.4% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.4% · Q3 5.1% · Q4 7.4% · 4Q avg 5.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.3%	21.6% 2.3 pts better	19.6% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 20.7% · Q3 20.3% · Q4 18.5% · 4Q avg 19.3%
Percentage of long-stay residents who received an antipsychotic medication	15.0%	15.0% About the same	16.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 15.2% · Q3 16.2% · Q4 15.4% · 4Q avg 15.0% · 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	7.2%	16.8% 9.6 pts better	14.9% 7.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 3.8% · Q3 5.4% · Q4 9.6% · 4Q avg 7.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	3.9%	0.9% 3 pts worse	1.0% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.6% · Q3 2.9% · Q4 3.0% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.0%	2.6% 0.6 pts better	1.7% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 1.6% · Q4 1.6% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.3%	21.2% 3.1 pts worse	19.8% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 28.3% · Q3 27.6% · Q4 23.2% · 4Q avg 24.3%
Percentage of long-stay residents with pressure ulcers	8.6%	6.0% 2.6 pts worse	5.1% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 9.7% · Q3 6.0% · Q4 8.1% · 4Q avg 8.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	78.7%	79.9% 1.2 pts worse	81.7% 3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 74.4% · Q2 83.8% · Q3 77.9% · Q4 78.8% · 4Q avg 78.7%
Percentage of short-stay residents who had an outpatient emergency department visit	13.0%	13.2% 0.2 pts better	12.0% 1 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 15.6% · Expected 13.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	73.2%	78.1% 4.9 pts worse	79.7% 6.5 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 73.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	33.0%	22.9% 10.1 pts worse	23.9% 9.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.0% · Observed 46.9% · Expected 33.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-08 · Fire 2024-05-07

2 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-05-07 · Fire 2022-12-01

4 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-12-01 · Fire 2019-11-21

4 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-07

K521 · Services Deficiencies

Fire Safety

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

Corrected 2024-07-27

F · Potential for more than minimal harm 2024-05-07

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 2024-07-27

D · Potential for more than minimal harm 2024-05-07

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 2024-07-27

D · Potential for more than minimal harm 2024-05-07

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-07-27

D · Potential for more than minimal harm 2024-05-07

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-07-27

F · Potential for more than minimal harm 2022-12-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-02-11

D · Potential for more than minimal harm 2022-12-01

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 2023-02-11

D · Potential for more than minimal harm 2022-12-01

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-02-11

F · Potential for more than minimal harm 2019-11-21

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2020-01-24

F · Potential for more than minimal harm 2019-11-21

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2020-01-24

F · Potential for more than minimal harm 2019-11-21

K521 · Services Deficiencies

Fire Safety

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

Corrected 2020-01-24

E · Potential for more than minimal harm 2019-11-21

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 2020-01-24

E · Potential for more than minimal harm 2019-11-21

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2020-01-24

E · Potential for more than minimal harm 2019-11-21

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2020-01-24

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-08

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-08-23

D · Potential for more than minimal harm 2025-08-08

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-08-23

E · Potential for more than minimal harm 2024-05-07

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-06-01

E · Potential for more than minimal harm 2024-05-07

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2024-06-01

D · Potential for more than minimal harm 2024-05-07

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-06-01

D · Potential for more than minimal harm 2024-05-07

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 2024-06-01

D · Potential for more than minimal harm 2023-09-01

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2023-08-04

E · Potential for more than minimal harm 2022-12-01

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 2022-12-29

E · Potential for more than minimal harm 2022-12-01

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 2022-12-29

D · Potential for more than minimal harm 2022-12-01

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-12-29

Penalties and ownership

What sits behind the stars

$4,709 2023-09-01

Fine

Fine · fine $4,709

Fine