Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Bethany Woods Nursing and Rehabilitation Center
Albemarle, NC · 180 certified beds · Last Life Safety survey December 19, 2024
CMS Certification Number 345146 · first certified March 1975
Ownership
Operated by PRINCIPLE LONG TERM CARE · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NC
5 citations — more than 16% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 1. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2026 to April 2026), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was December 2024. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 5 Life Safety citations above. The Physical Environment Index
- F-0584 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.
How that compares
Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 5 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 3, 2022 | 0 |
| September 1, 2023 | 2 |
| December 19, 2024 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0791 | Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | 1 | 2024-12-19 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-12-19 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2023-09-01 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-12-19 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-09-01 |
What the citations cover
- Smoke Deficiencies 3
- Miscellaneous Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 19, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 13, 2025) |
| K-0791 | Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Deficient, Provider has date of correction (March 13, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 13, 2025) |
September 1, 2023 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 17, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 17, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.