Starfile / North Carolina

Universal Health Care/North Raleigh

5201 Clarks Fork Drive NW, Raleigh, NC 27616 · CCN 345529

SFF

Inspection history vs North Carolina & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$326,170

Number of fines

3

Number of penalties

5

Payment denials

2

Chain

Chain

LIFEWORKS REHAB

Facilities in chain

59

Chain avg overall

2.10 / 5

Inspection citations (89)5 immediate jeopardy6 actual harm

1. DF0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.2025-08-20 · Health · corrected 2025-09-09

   Potential for more than minimal harm

2. DF0641Ensure each resident receives an accurate assessment.2025-08-20 · Health · corrected 2025-09-09

   Potential for more than minimal harm

3. DF0761Ensure 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.2025-08-20 · Health · corrected 2025-09-09

   Potential for more than minimal harm

4. DF0880Provide and implement an infection prevention and control program.2025-08-20 · Health · corrected 2025-09-09

   Potential for more than minimal harm

5. EF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-08-20 · Health · corrected 2025-08-01

   Potential for more than minimal harm

6. DF0887Educate 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.2025-08-20 · Health · corrected 2025-08-01

   Potential for more than minimal harm

7. DF0558Reasonably accommodate the needs and preferences of each resident.2025-02-24 · Health · corrected 2025-04-14

   Potential for more than minimal harm

8. EF0565Honor the resident's right to organize and participate in resident/family groups in the facility.2025-02-24 · Health · corrected 2025-04-14

   Potential for more than minimal harm

9. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-02-24 · Health · corrected 2025-04-14

   Potential for more than minimal harm

10. DF0583Keep residents' personal and medical records private and confidential.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

11. EF0584Honor 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.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

12. EF0602Protect each resident from the wrongful use of the resident's belongings or money.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

13. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

14. EF0641Ensure each resident receives an accurate assessment.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

15. GF0660Plan the resident's discharge to meet the resident's goals and needs.2025-02-24 · Health · corrected 2025-04-14

    Actual harm

16. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

17. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

18. DF0697Provide safe, appropriate pain management for a resident who requires such services.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

19. JF0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.2025-02-24 · Health · corrected 2025-04-14

    Immediate jeopardy

20. DF0727Have 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.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

21. EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-02-24 · Health · corrected 2025-05-06

    Potential for more than minimal harm

22. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

23. DF0759Ensure medication error rates are not 5 percent or greater.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

24. EF0760Ensure that residents are free from significant medication errors.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

25. EF0761Ensure 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.2025-02-24 · Health · corrected 2025-05-06

    Potential for more than minimal harm

26. FF0801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

27. EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

28. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

29. DF0847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

30. DF0848Provide a neutral and fair arbitration process and agree to arbitrator and venue.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

31. JF0880Provide and implement an infection prevention and control program.2025-02-24 · Health · corrected 2025-05-06

    Immediate jeopardy

32. FF0881Implement a program that monitors antibiotic use.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

33. DF0914Provide bedrooms that don't allow residents to see each other when privacy is needed.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

34. EF0940Develop, implement, and/or maintain an effective training program for all new and existing staff members.2025-02-24 · Health · corrected 2025-04-14

    Potential for more than minimal harm

35. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-11-07 · Health · corrected 2024-10-14

    Actual harm

36. GF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-09-12 · Health · corrected 2024-10-14

    Actual harm

37. DF0559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

38. JF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-09-12 · Health · corrected 2024-10-14

    Immediate jeopardy

39. DF0584Honor 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.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

40. JF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-09-12 · Health · corrected 2024-10-14

    Immediate jeopardy

41. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

42. DF0610Respond appropriately to all alleged violations.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

43. DF0624Prepare residents for a safe transfer or discharge from the nursing home.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

44. DF0635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

45. EF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

46. EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

47. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

48. DF0660Plan the resident's discharge to meet the resident's goals and needs.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

49. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

50. KF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-09-12 · Health · corrected 2024-10-14

    Immediate jeopardy

51. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

52. DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

53. DF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

54. EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

55. EF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

56. DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

57. DF0825Provide or get specialized rehabilitative services as required for a resident.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

58. EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-09-12 · Health · corrected 2024-10-14

    Potential for more than minimal harm

59. GF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2024-09-12 · Health · corrected 2024-10-14

    Actual harm

60. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

61. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

62. DF0694Provide for the safe, appropriate administration of IV fluids for a resident when needed.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

63. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

64. EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

65. DF0759Ensure medication error rates are not 5 percent or greater.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

66. EF0760Ensure that residents are free from significant medication errors.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

67. EF0835Administer the facility in a manner that enables it to use its resources effectively and efficiently.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

68. DF0849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

69. DF0880Provide and implement an infection prevention and control program.2024-08-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

70. EF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-06-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

71. DF0692Provide enough food/fluids to maintain a resident's health.2024-06-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

72. EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-06-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

73. EF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2024-06-06 · Health · corrected 2024-10-14

    Potential for more than minimal harm

74. GF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-01-10 · Health · corrected 2024-02-07

    Actual harm

75. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-01-10 · Health · corrected 2024-02-07

    Potential for more than minimal harm

76. EF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2024-01-10 · Health · corrected 2024-02-07

    Potential for more than minimal harm

77. GF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2023-11-30 · Health · corrected 2024-02-07

    Actual harm

78. EF0578Honor 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.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

79. EF0582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

80. BF0641Ensure each resident receives an accurate assessment.2023-11-30 · Health · corrected 2024-01-10

    Potential for minimal harm

81. DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

82. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

83. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

84. DF0727Have 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.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

85. EF0730Observe each nurse aide's job performance and give regular training.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

86. EF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

87. EF0758Implement 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.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

88. EF0803Ensure 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.2023-11-30 · Health · corrected 2024-01-10

    Potential for more than minimal harm

89. EF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2023-11-30 · Health · corrected 2024-02-07

    Potential for more than minimal harm

Ownership

No ownership records.

Other facilities in Raleigh

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.