Facility profile · CCN 345529
Universal Health Care/north Raleigh
89 federal citations on record , including 5 at the Immediate Jeopardy level, and 5 federal enforcement actions totaling $326,170.
Record summary
Federal record · Q1 202689
Total citations
89
Last 3 years
11
Actual harm+
5
Federal penalties
$326,170
Total fines
—
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
89 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Aug 20, 2025 | F887 | 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. | D | Standard |
| Aug 20, 2025 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E | Standard |
| Aug 20, 2025 | F880 | Provide and implement an infection prevention and control program. | D | Standard |
| Aug 20, 2025 | F761 | 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. | D | Standard |
| Aug 20, 2025 | F641 | Ensure each resident receives an accurate assessment. | D | Standard |
| Aug 20, 2025 | F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Standard |
| Feb 24, 2025 | F880 | Provide and implement an infection prevention and control program. | J | Complaint |
| Feb 24, 2025 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Complaint |
| Feb 24, 2025 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Complaint |
| Feb 24, 2025 | F761 | 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. | E | Complaint |
| Feb 24, 2025 | F760 | Ensure that residents are free from significant medication errors. | E | Complaint |
| Feb 24, 2025 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Complaint |
| Feb 24, 2025 | F726 | 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. | J | Complaint |
| Feb 24, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Feb 24, 2025 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Feb 24, 2025 | F660 | Plan the resident's discharge to meet the resident's goals and needs. | G | Complaint |
| Feb 24, 2025 | F602 | Protect each resident from the wrongful use of the resident's belongings or money. | E | Complaint |
| Feb 24, 2025 | F584 | 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. | E | Complaint |
| Feb 24, 2025 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Feb 24, 2025 | F940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | E | Standard |
| Feb 24, 2025 | F914 | Provide bedrooms that don't allow residents to see each other when privacy is needed. | D | Standard |
| Feb 24, 2025 | F881 | Implement a program that monitors antibiotic use. | F | Standard |
| Feb 24, 2025 | F848 | Provide a neutral and fair arbitration process and agree to arbitrator and venue. | D | Standard |
| Feb 24, 2025 | F847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | D | Standard |
| Feb 24, 2025 | F801 | 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. | F | Standard |
| Feb 24, 2025 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Feb 24, 2025 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Standard |
| Feb 24, 2025 | F727 | 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. | D | Standard |
| Feb 24, 2025 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Standard |
| Feb 24, 2025 | F641 | Ensure each resident receives an accurate assessment. | E | Standard |
| Feb 24, 2025 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Standard |
| Feb 24, 2025 | F583 | Keep residents' personal and medical records private and confidential. | D | Standard |
| Feb 24, 2025 | F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Standard |
| Feb 24, 2025 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
| Nov 7, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint |
| Sep 12, 2024 | F925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | G | Complaint |
| Sep 12, 2024 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Complaint |
| Sep 12, 2024 | F825 | Provide or get specialized rehabilitative services as required for a resident. | D | Complaint |
| Sep 12, 2024 | F806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | Complaint |
| Sep 12, 2024 | F757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | E | Complaint |
| Sep 12, 2024 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Complaint |
| Sep 12, 2024 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | D | Complaint |
| Sep 12, 2024 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Complaint |
| Sep 12, 2024 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Complaint |
| Sep 12, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K | Complaint |
| Sep 12, 2024 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Sep 12, 2024 | F660 | Plan the resident's discharge to meet the resident's goals and needs. | D | Complaint |
| Sep 12, 2024 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint |
| Sep 12, 2024 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Complaint |
| Sep 12, 2024 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | E | Complaint |
| Sep 12, 2024 | F635 | Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | D | Complaint |
| Sep 12, 2024 | F624 | Prepare residents for a safe transfer or discharge from the nursing home. | D | Complaint |
| Sep 12, 2024 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Sep 12, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Sep 12, 2024 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint |
| Sep 12, 2024 | F584 | 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. | D | Complaint |
| Sep 12, 2024 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | J | Complaint |
| Sep 12, 2024 | F559 | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | D | Complaint |
| Sep 12, 2024 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | G | Complaint |
| Aug 6, 2024 | F880 | Provide and implement an infection prevention and control program. | D | Complaint |
| Aug 6, 2024 | F849 | 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. | D | Complaint |
| Aug 6, 2024 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | E | Complaint |
| Aug 6, 2024 | F760 | Ensure that residents are free from significant medication errors. | E | Complaint |
| Aug 6, 2024 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Complaint |
| Aug 6, 2024 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Complaint |
| Aug 6, 2024 | F745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D | Complaint |
| Aug 6, 2024 | F694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D | Complaint |
| Aug 6, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Aug 6, 2024 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Jun 6, 2024 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E | Complaint |
| Jun 6, 2024 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Complaint |
| Jun 6, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Complaint |
| Jun 6, 2024 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E | Complaint |
| Jan 10, 2024 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E | Complaint |
| Jan 10, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Jan 10, 2024 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | G | Complaint |
| Nov 30, 2023 | F758 | 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. | E | Complaint |
| Nov 30, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Nov 30, 2023 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Complaint |
| Nov 30, 2023 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | G | Complaint |
| Nov 30, 2023 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E | Standard |
| Nov 30, 2023 | F803 | 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. | E | Standard |
| Nov 30, 2023 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E | Standard |
| Nov 30, 2023 | F730 | Observe each nurse aide's job performance and give regular training. | E | Standard |
| Nov 30, 2023 | F727 | 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. | D | Standard |
| Nov 30, 2023 | F644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Standard |
| Nov 30, 2023 | F641 | Ensure each resident receives an accurate assessment. | B | Standard |
| Nov 30, 2023 | F582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | E | Standard |
| Nov 30, 2023 | F578 | 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. | E | Standard |
Federal enforcement history
Federal regulators have imposed 5 enforcement actions against this facility, including 3 civil money penalties totaling $326,170 and 2 payment-denial actions spanning 78 days.
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Feb 24, 2025 | Fine | $111,432 | — |
| Feb 24, 2025 | Payment Denial | — | Mar 27, 2025 · 40 days |
| Jun 6, 2024 | Fine | $177,132 | — |
| Jun 6, 2024 | Payment Denial | — | Sep 6, 2024 · 38 days |
| Nov 30, 2023 | Fine | $37,606 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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