Cycle 1
Health 2025-05-08 · Fire 2025-05-08
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Raleigh, NC
Litchford Falls Health and Rehabilitation Center
1-star overall rating with 2-star inspections with $181,873 in total fines with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
8200 Litchford Road, Raleigh, NC
(919) 878-7772
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
2000-03-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing
LPN hours / resident day
0.93
Licensed practical nurse staffing
Aide hours / resident day
2.19
Nurse aide staffing
Weekend hours
3.26
Weekend nurse staffing
RN turnover
69%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.3% |
91.5%
14.2 pts worse
|
93.4%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.6%
0.3 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 20.5% |
4.8%
15.7 pts worse
|
11.4%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 10.8% |
7.2%
3.6 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
21.6%
12.2 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
15.0%
2.2 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.6% |
21.5%
18.1 pts worse
|
16.3%
23.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
16.8%
2.3 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.6%
0.6 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
21.2%
3.8 pts better
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
6.0%
1.8 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.4% |
79.9%
1.5 pts worse
|
81.7%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
13.2%
3.9 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.5%
0.8 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.0% |
78.1%
4.9 pts better
|
79.7%
3.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
22.9%
4.9 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-15
E · Potential for more than minimal harm
2025-05-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-05-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-15
D · Potential for more than minimal harm
2024-03-21
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-03-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-03-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-03-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-03-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-03-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-03-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-31
F · Potential for more than minimal harm
2022-12-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-02-19
F · Potential for more than minimal harm
2022-12-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-19
D · Potential for more than minimal harm
2022-12-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-19
D · Potential for more than minimal harm
2022-12-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-19
D · Potential for more than minimal harm
2022-12-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-19
D · Potential for more than minimal harm
2022-12-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-19
D · Potential for more than minimal harm
2022-12-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-19
D · Potential for more than minimal harm
2022-12-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-02-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-05
E · Potential for more than minimal harm
2025-05-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-08
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 2025-06-05
D · Potential for more than minimal harm
2025-05-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-08
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-02-17
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-06
J · Immediate jeopardy
2024-12-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-17
J · Immediate jeopardy
2024-12-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-01-16
J · Immediate jeopardy
2024-12-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-03-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-04-18
D · Potential for more than minimal harm
2023-09-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-30
Penalties and ownership
What sits behind the stars
$177,911
2024-12-17
Fine
Fine · fine $177,911
Fine
$3,962
2023-09-28
Fine
Fine · fine $3,962
Fine
Ownership
Beaver, Donald
5% Or Greater Direct Ownership Interest · Individual
Choice Health Management, Serv LLC
Operational/Managerial Control · Organization
Universal Health Care / Raleigh, Inc
Operational/Managerial Control · Organization
Yates, Brenda
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Universal Health Care/North Raleigh
Raleigh, NC
0-star overall rating with 0-star inspections with Special Focus status with $326,170 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
The Rosewood Health Center
Raleigh, NC
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Cardinal at North Hills
Raleigh, NC
4-star overall rating with 4-star inspections with $7,901 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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