Universal Health Care/North Raleigh
5201 Clarks Fork Drive NW, Raleigh, NC 27616 · All homes in Raleigh
Universal Health Care/North Raleigh, a 132-bed for profit - limited liability company nursing facility in Raleigh, NC, holds no current CMS overall rating - not currently rated against the 3.0-star national average, with nurse staffing below the national norm. 6 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 9198727033
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- N/A
- CMS overall · nat'l 3.0
- 3.88
- About average · nurse hrs/day · nat'l 3.89
- 50
- Inspection findings · 6 serious
- $326K
- Federal penalties (3)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 345529
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 132
- Residents
- 118
- In Hospital
- No
- County
- Wake
- Last Inspection
- Aug 20, 2025
- Special Focus
- SFF
Staffing Data
How the 3.88 total nursing hours per resident-day are staffed:
- RN Hours
- 0.61 (nat'l avg: 0.68)
- LPN Hours
- 0.99
- CNA Hours
- 2.28
- Total Nursing Hours
- 3.88 (nat'l avg: 3.89)
- PT Hours
- 0.12
- Nursing Turnover
- 66.9%
- RN Turnover
- 83.3%
What the CMS Record Reveals About Universal Health Care/North Raleigh
Universal Health Care/North Raleigh operates 132 certified beds in Raleigh, NC with approximately 118 residents currently in care, and carries a CMS overall rating of no current rating. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (N/A★), staffing levels (N/A★), and quality measures (N/A★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 6 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 3 penalties totaling $326K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.88 total nursing hours per resident day (national average 3.89), with RN coverage at 0.61 per resident day, the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Universal Health Care/North Raleigh falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 66.9%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
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.
Category: Infection Control Deficiencies
Corrected: Aug 1, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Aug 1, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 9, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Sep 9, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 9, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 9, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 6, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 14, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 14, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: May 6, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Apr 14, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Apr 14, 2025
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 14, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 14, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 14, 2025
Plan the resident's discharge to meet the resident's goals and needs.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 14, 2025
Protect each resident from the wrongful use of the resident's belongings or money.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 14, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Apr 14, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Apr 14, 2025
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Category: Administration Deficiencies
Corrected: Apr 14, 2025
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Category: Environmental Deficiencies
Corrected: Apr 14, 2025
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Apr 14, 2025
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Category: Administration Deficiencies
Corrected: Apr 14, 2025
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Category: Administration Deficiencies
Corrected: Apr 14, 2025
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 14, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Apr 14, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: May 6, 2025
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 14, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 14, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 14, 2025
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Apr 14, 2025
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Apr 14, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Category: Resident Rights Deficiencies
Corrected: Apr 14, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Apr 14, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Oct 14, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 14, 2024
Provide or get specialized rehabilitative services as required for a resident.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Oct 14, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Oct 14, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Oct 14, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Oct 14, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 14, 2024
Plan the resident's discharge to meet the resident's goals and needs.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 14, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 14, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 14, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Oct 14, 2024
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 18.9% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.2% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.1% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.1% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 12.6% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.7% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 22.5% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 10.6% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 13.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 92.6% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 12.0% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 82.5% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 30.9% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 93.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 86.8% | No |
Penalty History 3 penalties totaling $326K
| Date | Type | Amount |
|---|---|---|
| Feb 24, 2025 | Fine | $111K |
| Feb 24, 2025 | Payment Denial | - |
| Jun 6, 2024 | Fine | $177K |
| Jun 6, 2024 | Payment Denial | - |
| Nov 30, 2023 | Fine | $38K |
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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