CMS CCN 3454812026-08-01 PROCESSING DATE

NURSING HOME PUBLIC RECORD

Woodlands Nursing & Rehabilitation Center

400 Pelt Drive · Fayetteville, NC 28301 · Cumberland County

CMS OVERALL RATING★★★★☆4/5CMS field—not our score or recommendation

Certified beds80CMS provider file

Recent citation rows24current CMS citation release

Penalty rows1current 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.

01 / INSPECTION LEDGER

Survey cycles in this release

Cycle	Health date	Health deficiencies	Fire date	Fire deficiencies
Cycle 1	2025-08-08	2	2024-05-07	5
Cycle 2	2024-05-07	4	2022-12-01	3
Cycle 3	2022-12-01	4	2019-11-21	6

02 / CITATION DETAIL

24 rows in the current release

0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.

2025-08-08 · HEALTHF0641Severity D · isolated; potential for more than minimal harm

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Correction field: Deficient, Provider has date of correction · 2025-08-23

2025-08-08 · HEALTHF0644Severity D · isolated; potential for more than minimal harm

Resident Assessment and Care Planning Deficiencies

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

Correction field: Deficient, Provider has date of correction · 2025-08-23

2024-05-07 · HEALTHF0582Severity D · isolated; potential for more than minimal harm

Resident Rights Deficiencies

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

Correction field: Deficient, Provider has date of correction · 2024-06-01 · complaint

2024-05-07 · 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 · 2024-06-01 · complaint

2024-05-07 · HEALTHF0760Severity E · pattern; potential for more than minimal harm

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Correction field: Deficient, Provider has date of correction · 2024-06-01 · complaint

2024-05-07 · HEALTHF0887Severity E · pattern; potential for more than minimal harm

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.

Correction field: Deficient, Provider has date of correction · 2024-06-01 · complaint

2024-05-07 · FIREK0321Severity D · isolated; potential for more than minimal harm

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Correction field: Deficient, Provider has date of correction · 2024-07-27

2024-05-07 · FIREK0324Severity D · isolated; potential for more than minimal harm

Smoke Deficiencies

Provide properly protected cooking facilities.

Correction field: Deficient, Provider has date of correction · 2024-07-27

2024-05-07 · FIREK0372Severity D · isolated; potential for more than minimal harm

Smoke Deficiencies

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

Correction field: Deficient, Provider has date of correction · 2024-07-27

2024-05-07 · FIREK0521Severity F · widespread; 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 · 2024-07-27

2024-05-07 · FIREK0914Severity F · widespread; 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 · 2024-07-27

2023-09-01 · HEALTHF0660Severity D · isolated; potential for more than minimal harm

Resident Assessment and Care Planning Deficiencies

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

Correction field: Past Non-Compliance · 2023-08-04 · complaint

2022-12-01 · HEALTHF0578Severity D · isolated; potential for more than minimal harm

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.

Correction field: Deficient, Provider has date of correction · 2022-12-29

2022-12-01 · HEALTHF0742Severity E · pattern; potential for more than minimal harm

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.

Correction field: Deficient, Provider has date of correction · 2022-12-29

2022-12-01 · 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 · 2022-12-29

2022-12-01 · FIREK0321Severity D · isolated; potential for more than minimal harm

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Correction field: Deficient, Provider has date of correction · 2023-02-11

2022-12-01 · FIREK0353Severity F · widespread; potential for more than minimal harm

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Correction field: Deficient, Provider has date of correction · 2023-02-11

2022-12-01 · FIREK0372Severity D · isolated; potential for more than minimal harm

Smoke Deficiencies

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

Correction field: Deficient, Provider has date of correction · 2023-02-11

2019-11-21 · FIREK0222Severity E · pattern; potential for more than minimal harm

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.