Special Focus Facility

Overview

Address
5201 Clarks Fork Drive NW, Raleigh, NC 27616
Phone
9198727033
Certified beds
132
Avg daily residents
118 (89% of beds filled)
Ownership
For-profit LLC
Provider type
Medicare and Medicaid
Medicare/Medicaid since
2004-06-07
Setting
Urban
Rating not available

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
Footnote 18.
— Not Available
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
Footnote 18.
— Not Available
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
Footnote 18.
— Not Available
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
Footnote 18.
— Not Available

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
3.88 3.96 3.78 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
0.61 0.69 0.59 ≥ 0.55
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
0.99 0.88 0.96
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
2.28 2.39 2.22
Licensed (RN + LPN)
Combined licensed nurse coverage.
1.60
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
0.12

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
3.31
hrs / resident / day
RN (weekend)
0.40
hrs / resident / day
Total nurse (adjusted, weekend)
3.22
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
66.9%
annual
RN turnover
83.3%
annual
Administrators departed
3
last 12 months

Resident acuity

Nursing Case-Mix Index
1.40
higher acuity than avg
Case-Mix Index Ratio
1.02
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-08-20 6 6 0 28 1 28
Cycle 2/3 (prior) 2025-02-24 74 28 59 834 2 1,251
Total weighted health score
333.8
lower is better

Deficiencies (89)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

1 A/B/C No actual harm — minor
77 D/E/F Actual harm — potential for minor
6 G/H/I Actual harm
5 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. D 2025-08-20 2025-09-09
0641 Ensure each resident receives an accurate assessment. D 2025-08-20 2025-09-09
0761 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 2025-08-20 2025-09-09
0880 Provide and implement an infection prevention and control program. D 2025-08-20 2025-09-09
0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. E 2025-08-20 2025-08-01
0887 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 2025-08-20 2025-08-01
0558 Reasonably accommodate the needs and preferences of each resident. D 2025-02-24 2025-04-14
0565 Honor the resident's right to organize and participate in resident/family groups in the facility. E 2025-02-24 2025-04-14
0583 Keep residents' personal and medical records private and confidential. D 2025-02-24 2025-04-14
0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. D 2025-02-24 2025-04-14
0641 Ensure each resident receives an accurate assessment. E 2025-02-24 2025-04-14
0697 Provide safe, appropriate pain management for a resident who requires such services. D 2025-02-24 2025-04-14
0727 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 2025-02-24 2025-04-14
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. E 2025-02-24 2025-05-06
0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. D 2025-02-24 2025-04-14
0801 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 2025-02-24 2025-04-14
0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. D 2025-02-24 2025-04-14
0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. D 2025-02-24 2025-04-14
0881 Implement a program that monitors antibiotic use. F 2025-02-24 2025-04-14
0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. D 2025-02-24 2025-04-14
0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. E 2025-02-24 2025-04-14
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. D 2025-02-24 2025-04-14
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. E 2025-02-24 2025-04-14
0602 Protect each resident from the wrongful use of the resident's belongings or money. E 2025-02-24 2025-04-14
0660 Plan the resident's discharge to meet the resident's goals and needs. G 2025-02-24 2025-04-14
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2025-02-24 2025-04-14
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2025-02-24 2025-04-14
0726 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 2025-02-24 2025-04-14
0759 Ensure medication error rates are not 5 percent or greater. D 2025-02-24 2025-04-14
0760 Ensure that residents are free from significant medication errors. E 2025-02-24 2025-04-14
0761 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 2025-02-24 2025-05-06
0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. E 2025-02-24 2025-04-14
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2025-02-24 2025-04-14
0880 Provide and implement an infection prevention and control program. J 2025-02-24 2025-05-06
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. G 2024-11-07 2024-10-14
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. G 2024-09-12 2024-10-14
0559 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 2024-09-12 2024-10-14
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. J 2024-09-12 2024-10-14
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. D 2024-09-12 2024-10-14
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. J 2024-09-12 2024-10-14
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. D 2024-09-12 2024-10-14
0610 Respond appropriately to all alleged violations. D 2024-09-12 2024-10-14
0624 Prepare residents for a safe transfer or discharge from the nursing home. D 2024-09-12 2024-10-14
0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. D 2024-09-12 2024-10-14
0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted E 2024-09-12 2024-10-14
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. E 2024-09-12 2024-10-14
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2024-09-12 2024-10-14
0660 Plan the resident's discharge to meet the resident's goals and needs. D 2024-09-12 2024-10-14
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2024-09-12 2024-10-14
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. K 2024-09-12 2024-10-14

Showing 50 most recent of 89. See the All Data CSV for the full list.

Penalties (5)

Fines issued
3
last 3 years
Total fines
$326,170
Payment denials
2
Date Type Fine amount
2023-11-30 Fine $37,606
2025-02-24 Fine $111,432
2024-06-06 Fine $177,132
2025-02-24 Payment Denial
2024-06-06 Payment Denial

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 4.0% Medicaid 69.9% Other 26.1%

Operating performance

Operating Margin
5.7%
Total Margin
10.1%
Occupancy Rate
78.1%
Cost per Resident Day
$38

Revenue & costs

Net Patient Revenue
$11.5M
Total Costs
$1.4M
Net Income
$1.2M

Balance sheet

Total Assets
$3.3M
Total Liabilities
$281K
Fund Balance
$3.0M
Current Ratio
10.68

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: LIFEWORKS REHAB

Chain ID
768
Facilities in chain
59
Legal business name
Legal Business Name Not Available
Chain-average star ratings (for peer context)
Overall
2.1
Health
2.1
Staffing
1.5
QM
3.9

Owner / manager individuals (1)

Name Role Association
Ownership Data Not Available

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Special focus status
SFF
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $38 metrics.cost_per_resident_day
Cost Report Current Ratio 10.68 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 69.9% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 4.0% metrics.medicare_day_share
Cost Report Net Income ($) $1,223,197 metrics.net_income
Cost Report Net Patient Revenue ($) $11,535,014 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 78.1% metrics.occupancy_rate
Cost Report Operating Margin (%) 5.7% metrics.operating_margin
Cost Report Total Assets ($) $3,260,048 metrics.total_assets
Cost Report Total Costs ($) $1,416,921 metrics.total_costs
Cost Report Total Fund Balances ($) $2,978,882 metrics.fund_balance
Cost Report Total Liabilities ($) $281,166 metrics.total_liabilities
Cost Report Total Margin (%) 10.1% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.96409 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 2.22296 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.59141 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.77847 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 3.22149 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 117.8 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.87906 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.38908 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.69289 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.96103 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.49123 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.1 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.1 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 3.9 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 1.5 Chain Average Staffing Rating
Provider Information Chain ID 768 Chain ID
Provider Information Chain Name LIFEWORKS REHAB Chain Name
Provider Information City/Town Raleigh City/Town
Provider Information CMS Certification Number (CCN) 345529 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Wake County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 2004-06-07 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote Geocoding Footnote
Provider Information Health Inspection Rating Health Inspection Rating
Provider Information Health Inspection Rating Footnote 18 Health Inspection Rating Footnote
Provider Information Latitude 35.8897 Latitude
Provider Information Legal Business Name Legal Business Name Not Available Legal Business Name
Provider Information Location 5201 Clarks Fork Drive NW,Raleigh,NC,27616 Location
Provider Information Long-Stay QM Rating Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote 18 Long-Stay QM Rating Footnote
Provider Information Longitude -78.556 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 3 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 132 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 59 Number of Facilities in Chain
Provider Information Number of Fines 3 Number of Fines
Provider Information Number of Payment Denials 2 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.40321 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 1.01856 Nursing Case-Mix Index Ratio
Provider Information Overall Rating Overall Rating
Provider Information Overall Rating Footnote 18 Overall Rating Footnote
Provider Information Ownership Type For profit - Limited Liability company Ownership Type
Provider Information Physical Therapist Staffing Footnote Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 5201 Clarks Fork Drive NW Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name Universal Health Care/North Raleigh Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 910 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating QM Rating
Provider Information QM Rating Footnote 18 QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 28 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 0 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 6 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-08-20 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 28 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 6 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 28 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2025-02-24 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 834 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 417 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 59 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 2 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 1251 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 74 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.39524 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 83.3 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.59583 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.98909 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 2.28060 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.11531 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.60675 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.87643 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote 18 Short-Stay QM Rating Footnote
Provider Information Special Focus Status SFF Special Focus Status
Provider Information Staffing Rating Staffing Rating
Provider Information Staffing Rating Footnote 18 Staffing Rating Footnote
Provider Information State NC State
Provider Information Telephone Number 9198727033 Telephone Number
Provider Information Total Amount of Fines in Dollars 326170.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 3.30501 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 5 Total Number of Penalties
Provider Information Total nursing staff turnover 66.9 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 333.750 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 27616 ZIP Code