Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodlands Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with COPD and dependent on supplemental oxygen was not accurately coded for oxygen therapy on the MDS assessment due to operator error by the MDS Coordinator. The care plan documented the need for oxygen, and the resident was observed receiving it, but the MDS did not reflect this intervention.
A resident was readmitted with new mental health diagnoses, including major depressive disorder, PTSD, and adjustment disorder with anxiety. Despite these diagnoses, staff did not complete the required PASRR level II screening, as the responsibility was overlooked and not identified before the survey.
The facility failed to administer significant medications to four residents and did not follow medication administration guidelines for another resident. Staff interviews revealed that a nurse was overwhelmed with tasks, leading to missed doses, and there was a lack of awareness about which medications should not be crushed.
The facility failed to document and track COVID-19 vaccination status, eligibility screening, education, and offering of the vaccine for four staff members. Interviews with the IP, DON, and Interim Administrator confirmed the lack of documentation and tracking, with the IP only beginning to maintain records after the survey team requested the information.
The facility failed to provide a CMS-10123 Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the discharge from Medicare Part A services for a resident. The NOMNC letter was issued five days after the end of skilled services, and the Business Office Manager acknowledged the delay. Interviews confirmed that the NOMNC should have been provided before the end of services.
A resident's medication regimen was not adjusted according to the consultant pharmacist's recommendations, leading to a deficiency. The resident had multiple diagnoses and was on several medications that were being crushed, which is inappropriate for extended-release formulations. Despite recommendations for changes, only one medication was adjusted, and there was no documentation for the others.
Failure to Accurately Code Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident who was dependent on supplemental oxygen and had a diagnosis of chronic obstructive pulmonary disease (COPD). The resident was observed receiving continuous oxygen therapy via nasal cannula, and the care plan reflected the need for oxygen therapy. However, the MDS assessment did not indicate that the resident was receiving oxygen therapy due to operator error by the MDS Coordinator. Interviews with the resident, MDS Coordinator, DON, and Administrator confirmed that the omission was not in line with facility expectations and was attributed to a coding error.
Failure to Complete PASRR Level II Screening for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident who was readmitted with newly identified mental health diagnoses, including major depressive disorder, post-traumatic stress disorder, and adjustment disorder with anxiety. Upon readmission, the resident was cognitively intact and had not previously been considered for a PASRR level II screening, as earlier records from 2010 showed no mental health diagnoses. However, at the time of readmission, the resident did have these diagnoses, which should have triggered a PASRR level II screening. Staff interviews confirmed that the responsibility to submit the PASRR level II screening was overlooked by the Social Worker, and this omission was not identified or corrected prior to the survey investigation.
Medication Administration Failures
Penalty
Summary
The facility failed to administer significant medications to four residents and did not follow medication administration guidelines for another resident. Resident #1 did not receive her scheduled medications for heart failure, seizures, and diabetes on the morning of 11/29/23. Similarly, Resident #18 missed his medications for schizophrenia and hypertension on the same day. Resident #21 also did not receive his antiseizure and antihypertensive medications, and Resident #48 missed her diabetes and hypertension medications. Interviews with staff revealed that the nurse responsible for administering these medications was called in at the last minute and was overwhelmed with other tasks, leading to the missed doses. The Director of Nursing and the Unit Supervisor were not aware of the missed medications, and the physician was not informed of the issue. Additionally, the facility failed to follow medication administration guidelines for Resident #42, who was on a mechanically altered diet and had difficulty swallowing. Despite a pharmacy consultant's review recommending alternative forms of medication, the resident's medications, including enteric-coated and extended-release tablets, were crushed before administration. Interviews with nurses revealed a lack of awareness about which medications should not be crushed, and there was no clear indication in the electronic medical record or on the medication cart. The deficiencies in medication administration and adherence to guidelines were identified through record reviews and staff interviews. The facility's failure to ensure that medications were administered as prescribed and to follow proper guidelines for medication administration posed potential risks to the residents' health and safety. The lack of communication and awareness among staff contributed to these deficiencies, highlighting the need for better oversight and training in medication management.
Failure to Document and Track COVID-19 Vaccination for Staff
Penalty
Summary
The facility failed to maintain documentation of current COVID-19 vaccination status, eligibility screening, education, and offering of COVID-19 vaccination for four staff members. The facility's COVID-19 Staff Vaccination Policy required that all newly hired employees be offered the COVID-19 vaccine and that a master tracker be maintained to list all current staff and their vaccination status. However, records revealed that four staff members hired between January and April 2024 had no documentation of being screened for vaccine eligibility, offered the vaccine, or educated on the benefits, risks, and potential side effects of the vaccine. Interviews with the facility's Infection Preventionist (IP), Director of Nursing (DON), and Interim Administrator confirmed the lack of documentation and tracking. The IP, who started working at the facility in January 2024, was unaware that staff vaccination records were not kept and only began maintaining these records after the survey team requested the information. The DON assumed that the previous IP was responsible for tracking staff vaccination status and providing education. The Interim Administrator acknowledged the deficiency and stated that going forward, new hires would be screened, offered the vaccine, and educated, with the IP or designee ensuring accurate tracking and documentation.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a CMS-10123 Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the discharge from Medicare Part A services for a resident. The resident was admitted to the facility under skilled Medicare Part A services to receive physical, occupational, and speech therapy. The resident's cognition was intact, and she was dependent on staff for eating, toileting, and personal hygiene. The rehabilitation services for the resident ended on 11/23/2023, but the NOMNC letter was not issued until 11/28/2023, five days after the services ended. The Business Office Manager was responsible for issuing the NOMNC letter but failed to do so in a timely manner. Interviews with the Social Worker, Rehabilitation Director, and Business Office Manager revealed that the NOMNC letter should have been provided to the resident or the Responsible Party (RP) before the end of the skilled services on 11/23/2023. The Business Office Manager acknowledged that it was her responsibility to notify the family and check if they had filed for a NOMNC appeal. The interim Administrator confirmed that it was the facility's expectation to provide appropriate notices prior to discharging residents from Medicare services. The delay in issuing the NOMNC letter resulted in the resident and RP being informed of the end of skilled services later than required by regulations.
Failure to Address Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to respond to the consultant pharmacist's recommendations for a resident reviewed for unnecessary medications. Resident #42, who was admitted with multiple diagnoses including atrial fibrillation, gastroesophageal reflux disease, and arthritis, had several medications prescribed upon admission. The consultant pharmacist reviewed the resident's drug regimen and recommended changes to several medications due to the resident's medications being crushed, which is not appropriate for extended-release formulations. These recommendations included changing Cardizem to diltiazem, switching enteric-coated aspirin to chewable aspirin, changing Protonix to a granule packet, adjusting the Tylenol dosage, and evaluating an alternative for pentoxifylline. However, there was no documentation in the resident's medical record indicating that these recommendations were addressed, except for a note stating that the Cardizem was changed to twice a day without further changes per the Nurse Practitioner (NP). The NP confirmed that she had changed the Cardizem dosage due to increased episodes of atrial fibrillation but did not address the other medications at that time. Interviews with the Director of Nursing (DON), the NP, the Regional Director of Operations, and the Pharmacy Consultant revealed gaps in communication and follow-up regarding the pharmacist's recommendations. The DON stated that she forwards the recommendations to the physician but does not always receive them back. The NP mentioned that nursing staff usually communicate pharmacy recommendations to her, but she was unaware of why the other medication changes were not addressed. The Regional Director of Operations indicated that physicians should respond to the pharmacist's recommendations, and the Pharmacy Consultant expected a documented rationale if the physician chose not to change a resident's medication. This lack of response and documentation led to the deficiency identified in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fayetteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland House Rehabilitation And Healthcare | 0.5 mi | ★★★★★ | 6 | 0 |
| Haymount Rehabilitation & Nursing Center, Inc. | 1.2 mi | ★★★★★ | 0 | 0 |
| Whispering Pines Nursing & Rehab Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Village Green Health And Rehabilitation | 3.3 mi | ★★★★★ | 3 | 0 |
| Bethesda Health Care Facility | 4.9 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.