Cycle 1
Health 2025-08-20 · Fire 2025-02-24
6 health deficiencies
Top issue: Infection Control (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Raleigh, NC
Universal Health Care/North Raleigh
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
5201 Clarks Fork Drive NW, Raleigh, NC
(919) 872-7033
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
2004-06-07
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
0.61
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,829
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.39
Baseline 20.07% · Performance 19.86% · Measure score 3.39 · Achievement 3.39 · Improvement 0.18
Healthcare-associated infections
0.69
Baseline 6.83% · Performance 7.63% · Measure score 0.69 · Achievement 0.69 · Improvement 0
Total nurse turnover
0
Baseline 55.74% · Performance 63.51% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.79 hours · Performance 2.58 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.93% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 11.29% · Lower 95% interval 7.38% |
| Discharge to community | 46.39% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 37.04% · Lower 95% interval 35.74% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 85.87% |
95.27%
9.4 pts worse
|
Numerator 79 · Denominator 92 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 92 |
| Discharge self-care score | 59.26% |
53.69%
5.6 pts better
|
Numerator 32 · Denominator 54 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 24 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.09% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 92 · Adjusted rate 0.84% |
| Healthcare-associated infections requiring hospitalization | 7.63% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 10.2% · Lower 95% interval 4.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 90 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 116 |
| Discharge function score | 59.26% |
56.45%
2.8 pts better
|
Numerator 32 · Denominator 54 |
| Transfer of health information to provider | 81.58% |
95.95%
14.4 pts worse
|
Numerator 31 · Denominator 38 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 17.54% |
25.2%
7.7 pts worse
|
Numerator 10 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.7 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
91.5%
1.1 pts better
|
93.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 98.9% · Q3 86.9% · Q4 88.4% · 4Q avg 92.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.5% |
94.1%
11.6 pts worse
|
95.5%
13 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.6%
1.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 3.0% · Q4 3.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.3% |
4.8%
8.5 pts worse
|
11.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 12.3% · Q3 11.8% · Q4 26.4% · 4Q avg 13.3% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
7.2%
3.4 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 11.5% · Q3 13.0% · Q4 12.9% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
21.6%
9.6 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 16.2% · Q3 10.9% · Q4 9.4% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.5% |
15.0%
7.5 pts worse
|
16.7%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 19.4% · Q3 25.3% · Q4 20.5% · 4Q avg 22.5% · 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 | 12.6% |
21.5%
8.9 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 18.9% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.9% |
16.8%
2.1 pts worse
|
14.9%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 20.8% · Q3 22.6% · Q4 13.0% · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.2% · Q3 3.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
21.2%
9.7 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.9% · Q2 28.3% · Q3 30.0% · Q4 24.5% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
6.0%
1.3 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.6% · Q3 4.6% · Q4 5.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
79.9%
13.3 pts better
|
81.7%
11.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 100.0% · Q3 93.8% · Q4 85.6% · 4Q avg 93.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.6% |
13.2%
5.4 pts worse
|
12.0%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 20.7% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 1.1% · Q4 2.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.8% |
78.1%
8.7 pts better
|
79.7%
7.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
22.9%
7.3 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 31.7% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-24 · Fire 2023-11-30
67 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-11-30 · Fire 2022-08-11
16 health deficiencies
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-24
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 2025-06-16
F · Potential for more than minimal harm
2025-02-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-16
F · Potential for more than minimal harm
2025-02-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-16
F · Potential for more than minimal harm
2025-02-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-02-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-02-24
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-02-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-16
F · Potential for more than minimal harm
2023-11-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-28
F · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-28
F · Potential for more than minimal harm
2023-11-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-28
F · Potential for more than minimal harm
2023-11-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-28
F · Potential for more than minimal harm
2023-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-28
F · Potential for more than minimal harm
2023-11-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-28
D · Potential for more than minimal harm
2023-11-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-28
D · Potential for more than minimal harm
2023-11-30
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 2024-02-28
D · Potential for more than minimal harm
2023-11-30
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-02-28
D · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-28
D · Potential for more than minimal harm
2023-11-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-28
D · Potential for more than minimal harm
2023-11-30
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-02-28
D · Potential for more than minimal harm
2023-11-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-28
D · Potential for more than minimal harm
2022-08-11
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-08-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-08-11
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 2022-10-22
D · Potential for more than minimal harm
2022-08-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-08-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-08-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-08-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-22
D · Potential for more than minimal harm
2022-08-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-08-20
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-20
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 2025-09-09
D · Potential for more than minimal harm
2025-08-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-20
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-08-01
J · Immediate jeopardy
2025-02-24
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-04-14
J · Immediate jeopardy
2025-02-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-06
G · Actual harm
2025-02-24
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-02-24
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-02-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-24
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-24
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 2025-04-14
E · Potential for more than minimal harm
2025-02-24
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-06
E · Potential for more than minimal harm
2025-02-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-24
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 2025-05-06
E · Potential for more than minimal harm
2025-02-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-02-24
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-24
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 2025-04-14
D · Potential for more than minimal harm
2025-02-24
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-24
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 2025-04-14
D · Potential for more than minimal harm
2025-02-24
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 2025-04-14
D · Potential for more than minimal harm
2025-02-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-24
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-24
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 2025-04-14
D · Potential for more than minimal harm
2025-02-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-24
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 2025-04-14
D · Potential for more than minimal harm
2025-02-24
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-24
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-24
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-04-14
G · Actual harm
2024-11-07
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 2024-10-14
K · Immediate jeopardy
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-14
J · Immediate jeopardy
2024-09-12
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 2024-10-14
J · Immediate jeopardy
2024-09-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-14
G · Actual harm
2024-09-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-14
G · Actual harm
2024-09-12
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-09-12
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 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
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 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
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 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
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 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-12
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-08-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-08-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-08-06
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-06
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 2024-10-14
D · Potential for more than minimal harm
2024-08-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-06
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-06
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-06
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-06-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-06-06
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 2024-10-14
E · Potential for more than minimal harm
2024-06-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-06-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-14
G · Actual harm
2024-01-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-07
E · Potential for more than minimal harm
2024-01-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-07
G · Actual harm
2023-11-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-07
E · Potential for more than minimal harm
2023-11-30
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 2024-01-10
E · Potential for more than minimal harm
2023-11-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-30
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-30
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 2024-01-10
E · Potential for more than minimal harm
2023-11-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-30
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-07
D · Potential for more than minimal harm
2023-11-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-30
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 2024-01-10
D · Potential for more than minimal harm
2023-11-30
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-01-10
B · Minimal harm
2023-11-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-10
Penalties and ownership
What sits behind the stars
$111,432
2025-02-24
Fine
Fine · fine $111,432
Fine
$0
2025-02-24
Payment Denial
Payment Denial · denial start 2025-03-27 · 40 days
40 day denial
$177,132
2024-06-06
Fine
Fine · fine $177,132
Fine
$0
2024-06-06
Payment Denial
Payment Denial · denial start 2024-09-06 · 38 days
38 day denial
$37,606
2023-11-30
Fine
Fine · fine $37,606
Fine
Ownership
Nearby options
Other facilities in reach
#1
Litchford Falls Health and Rehabilitation Center
Raleigh, NC
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
#2
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
#3
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
Jump out