A-
85/100Woodlands Nursing & Rehabilitation Center Inspection Report, Violations & Safety Grade (Fayetteville, North Carolina)
400 Pelt Drive, Fayetteville, North Carolina 28301
Phone: 9108220515
CMS Overall:4/5
Overview & Bed Count
Certified Beds
80
Avg Residents/Day
74.9
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Cumberland
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health4/5
Staffing3/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | North Carolina Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.40 | 0.62 | -0.22 |
| Total Nurse Hours per Resident per Day | 3.83 | 3.87 | -0.05 |
| CMS Staffing Rating | 3/5 | 2.7/5 | - |
| Nursing Staff Turnover | 48.8% | 48.7% | - |
Health Citation History
9 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-08-08 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2025-08-08 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2024-05-07 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | E – Moderate Harm Potential |
| 2024-05-07 | Infection Control Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-05-07 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D – Moderate Harm Potential |
| 2024-05-07 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2022-12-01 | Quality of Life and Care Deficiencies | 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. | E – Moderate Harm Potential |
| 2022-12-01 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2022-12-01 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
Fire Safety Citation History
14 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-05-07 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2024-05-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | F – Moderate Harm Potential |
| 2024-05-07 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2024-05-07 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2024-05-07 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2022-12-01 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2022-12-01 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2022-12-01 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2019-11-21 | Smoke Deficiencies | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | F – Moderate Harm Potential |
| 2019-11-21 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2019-11-21 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2019-11-21 | Egress Deficiencies | 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. | E – Moderate Harm Potential |
| 2019-11-21 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2019-11-21 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Fayetteville area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.