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
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
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
0.43
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,483
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.73% · Performance 24.08% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.45
Baseline 7.93% · Performance 7.40% · Measure score 1.45 · Achievement 1.45 · Improvement 1.31
Total nurse turnover
5.2
Baseline 32.35% · Performance 42.42% · Measure score 5.2 · Achievement 5.2 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.63 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 166 · Observed rate 10.24% · Lower 95% interval 7.52% |
| Discharge to community | 56.03% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 178 · Observed rate 50% · Lower 95% interval 48.28% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.33% |
95.27%
3.1 pts better
|
Numerator 294 · Denominator 299 |
| Falls with major injury | 1.67% |
0.77%
0.9 pts worse
|
Numerator 5 · Denominator 299 |
| Discharge self-care score | 70.88% |
53.69%
17.2 pts better
|
Numerator 129 · Denominator 182 |
| Discharge mobility score | 30.22% |
50.94%
20.7 pts worse
|
Numerator 55 · Denominator 182 |
| Pressure ulcers or injuries, new or worsened | 4.38% |
2.29%
2.1 pts worse
|
Numerator 13 · Denominator 297 · Adjusted rate 3.61% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 8.33% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 15.25% |
8.2%
7.1 pts better
|
Numerator 18 · Denominator 118 |
| Staff flu vaccination coverage | 31.4% |
42%
10.6 pts worse
|
Numerator 38 · Denominator 121 |
| Discharge function score | 46.7% |
56.45%
9.8 pts worse
|
Numerator 85 · Denominator 182 |
| Transfer of health information to provider | 97.7% |
95.95%
1.8 pts better
|
Numerator 170 · Denominator 174 |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 90 · Denominator 100 |
| Resident COVID-19 vaccinations up to date | 62.89% |
25.2%
37.7 pts better
|
Numerator 122 · Denominator 194 |
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 · Adjusted 2.4 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 2.3 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 64.4% · Q2 60.0% · Q3 88.0% · Q4 100.0% · 4Q avg 77.3% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 6.8% · Q2 4.0% · Q3 2.0% · Q4 2.1% · 4Q avg 3.9% · Used in QM five-star |
| 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 · Q1 9.3% · Q2 19.6% · Q3 22.2% · Q4 33.3% · 4Q avg 20.5% |
| 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 · Q1 9.4% · Q2 11.1% · Q3 13.0% · Q4 9.8% · 4Q avg 10.8% |
| 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 · Q1 14.8% · Q2 8.5% · Q3 6.4% · Q4 7.0% · 4Q avg 9.4% |
| 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 · Q1 12.2% · Q2 15.0% · Q3 13.2% · Q4 10.8% · 4Q avg 12.8% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 39.6% · Used in QM five-star |
| 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 · Q1 16.7% · Q2 17.1% · Q3 7.7% · Q4 15.8% · 4Q avg 14.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.6% · 4Q avg 0.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 6.5% · 4Q avg 2.0% · Used in QM five-star |
| 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 · Q1 10.4% · Q2 26.4% · Q3 11.9% · Q4 21.7% · 4Q avg 17.4% |
| 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 · Q1 5.3% · Q2 5.1% · Q3 4.2% · Q4 2.1% · 4Q avg 4.2% · Used in QM five-star |
| 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 · Q1 76.1% · Q2 78.6% · Q3 75.3% · Q4 83.5% · 4Q avg 78.4% |
| 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 · Adjusted 17.1% · Observed 16.8% · Expected 10.9% · Used in QM five-star |
| 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 · Q1 0.7% · Q2 1.7% · Q3 3.4% · Q4 3.2% · 4Q avg 2.3% · Used in QM five-star |
| 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 · 4Q avg 83.0% |
| 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 · Adjusted 27.8% · Observed 26.6% · Expected 22.8% · Used in QM five-star |
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
Jump out