01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-29 | 7 | 2024-09-12 | 4 |
| Cycle 2 | 2024-09-12 | 3 | 2023-05-18 | 9 |
| Cycle 3 | 2023-05-18 | 14 | 2022-01-24 | 4 |
CMS CCN 3450542026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Woodhaven Nursing Center
1150 Pine Run Drive · Lumberton, NC 28358 · Robeson County
Certified beds115CMS provider file
Recent citation rows41current CMS citation release
Penalty rows4current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
41 rows in the current release
5 rows carry G–L scope/severity codes; 3 carry J–L. 11 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-08-29 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-08-29 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: No revisit needed · 2025-10-012025-08-29 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-08-29 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-08-29 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-08-29 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-08-29 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-012024-09-12 · HEALTHF0684Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-09-192024-09-12 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-09-192024-09-12 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-192024-09-12 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-11-302024-09-12 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-11-302024-09-12 · FIREK0914Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-11-302024-09-12 · FIREK0923Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2024-11-302024-07-31 · HEALTHF0600Severity J · isolated immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-09-12 · complaint2024-07-31 · HEALTHF0607Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2024-09-12 · complaint2024-07-31 · HEALTHF0684Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-09-19 · complaint2024-05-31 · HEALTHF0686Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-06-21 · complaint2024-05-31 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-06-05 · complaint2024-04-24 · HEALTHF0745Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Correction field: Deficient, Provider has date of correction · 2024-05-31 · complaint2024-04-24 · HEALTHF0867Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2024-05-31 · complaint2023-12-15 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-01-11 · complaint2023-12-15 · HEALTHF0745Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Correction field: Deficient, Provider has date of correction · 2024-01-11 · complaint2023-05-18 · HEALTHF0625Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-06-0503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-07-31 | Fine | $94,175 | 0 |
| 2024-07-31 | Payment Denial | $0 | 26 |
| 2024-04-24 | Fine | $9,718 | 0 |
| 2023-12-15 | Fine | $24,317 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LIBERTY COMMONS OF ROBESON COUNTY, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2023
- LIBERTY REAL PROPERTIES II LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2023
- LIBERTY REAL PROPERTIES VII LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 10/01/2023
- LIBERTY HEALTHCARE GROUP LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 10/01/2023
- CALCUTT, JOSEPHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2023
- WILSON, JEFFREYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2023
- KLING, ASHLEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2023
- MCNEILL, JOHNIndividual · LIMITED PARTNERSHIP INTERESTNOT APPLICABLE · since 10/01/2023
- WILSON, JEFFREYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 08/13/2025
- MCNEILL, JOHNIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 10/01/2023
- LIBERTY HEALTHCARE GROUP LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/20/2024
- LIBERTY LONG TERM CARE LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/06/2024
- LONG TERM CARE MANAGEMENT SERVICES LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/09/2024
- RONALD B. AND CYNTHIA J. MCNEILL 2013 IRREVOCABLE TRUSTOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/09/2024
- CALCUTT, JOSEPHIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2023
- KLING, ASHLEYIndividual · ADP OF THE SNFNOT APPLICABLE · since 08/13/2025
- WILSON, JEFFREYIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.89per resident day
RN hours0.31per resident day
Weekend nurse hours3.65per resident day
Staff turnover58.6%CMS reported field
06 / LOCAL RECORDS
Open the Lumberton ledger →