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

Staffing

Hours and turnover

RN hours / resident day

0.36

Registered nurse staffing

LPN hours / resident day

0.92

Licensed practical nurse staffing

Aide hours / resident day

2.71

Nurse aide staffing

Weekend hours

3.71

Weekend nurse staffing

RN turnover

50%

Annual RN turnover

Total nurse turnover

57%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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	7.2%	16.8% 9.6 pts better	14.9% 7.7 pts better	Long Stay · 2024Q4-2025Q3
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
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
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
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
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
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
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
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
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

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