Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Carol Woods
Chapel Hill, NC · 30 certified beds · Last Life Safety survey June 6, 2024
CMS Certification Number 345199 · first certified January 1980
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NC
8 citations — more than 34% 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 7 citations; the earlier surveys in the window averaged 0.5. 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 (July 2025 to October 2025), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was June 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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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 | 8 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 7, 2021 | 1 |
| February 9, 2023 | 0 |
| June 6, 2024 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2024-06-06 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-06-06 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2024-06-06 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2024-06-06 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-06-06 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-06-06 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2021-10-07 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-06-06 |
What the citations cover
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 6, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 9, 2024) |
October 7, 2021 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (October 25, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.