Cycle 1
Health 2025-06-26 · Fire 2024-06-06
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Chapel Hill, NC
Carol Woods
5-star overall rating with 4-star inspections with 7 fire-safety deficiencies in the latest cycle
750 Weaver Dairy Road, Chapel Hill, NC
(919) 968-4511
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-01-30
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.94
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.63
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
6.13
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.50
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
5.52
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.51
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
2.03
CMS adjusted RN staffing hours
Adjusted total hours
6.40
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
17%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,932
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0076
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.36
Performance 19.41% · Measure score 4.36 · Achievement 4.36 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.4
Performance 6.22% · Measure score 5.4 · Achievement 5.4 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.13
Baseline 23.68% · Performance 38.64% · Measure score 6.13 · Achievement 6.13 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 3.08% · Lower 95% interval 6.11% |
| Discharge to community | 59.35% |
50.57%
8.8 pts better
|
Better than the National Rate · Eligible stays 64 · Observed rate 65.63% · Lower 95% interval 51.37% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 35.9% |
95.27%
59.4 pts worse
|
Numerator 14 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 62.86% |
53.69%
9.2 pts better
|
Numerator 22 · Denominator 35 |
| Discharge mobility score | 85.71% |
50.94%
34.8 pts better
|
Numerator 30 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.22% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 0% · Lower 95% interval 3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 407 |
| Staff flu vaccination coverage | 94.24% |
42%
52.2 pts better
|
Numerator 393 · Denominator 417 |
| Discharge function score | 82.86% |
56.45%
26.4 pts better
|
Numerator 29 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 34 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 86.96% |
25.2%
61.8 pts better
|
Numerator 20 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
91.5%
3.7 pts better
|
93.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
4.8%
2.2 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 11.1% |
7.2%
3.9 pts worse
|
5.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.6% |
21.6%
19 pts better
|
19.6%
17 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
15.0%
11.8 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
16.8%
2.6 pts worse
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.9%
1.2 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 32.5% |
2.6%
29.9 pts worse
|
1.7%
30.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.7% |
21.2%
4.5 pts better
|
19.8%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.0%
6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
79.9%
12.9 pts better
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.6% · Q2 98.0% · Q3 91.1% · Q4 89.7% · 4Q avg 92.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
13.2%
13.2 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 8.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
78.1%
20.9 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.7% |
22.9%
13.2 pts better
|
23.9%
14.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 5.9% · Expected 14.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2023-02-09
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-02-09 · Fire 2021-10-07
2 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-06
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-09
D · Potential for more than minimal harm
2021-10-07
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2021-10-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-06-06
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-06-29
E · Potential for more than minimal harm
2024-06-06
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 2024-06-29
E · Potential for more than minimal harm
2024-06-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-29
B · Minimal harm
2024-06-06
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-06-29
B · Minimal harm
2024-06-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-29
D · Potential for more than minimal harm
2023-02-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-09
Penalties and ownership
What sits behind the stars
Ownership
The Chapel Hill Residential Retirement Center, Inc.
5% Or Greater Direct Ownership Interest · Organization
Biesecker, Tracy
Corporate Officer · Individual
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