Inspection Reports for
Carol Woods
750 Weaver Dairy Rd, Chapel Hill, NC 27514, USA, NC, 27514
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
56% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at the nursing home.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 6, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, food safety, staffing, and immunization policies.
Findings
The facility was found deficient in multiple areas including failure to timely transmit Minimum Data Set (MDS) assessments, failure to review and revise resident care plans after falls, improper food labeling and storage practices, inaccurate submission of payroll-based journal staffing data, and failure to provide education and offer up-to-date pneumococcal vaccinations to residents.
Deficiencies (5)
F 0640: The facility failed to ensure MDS assessments were transmitted timely and accepted by CMS for 2 of 9 residents reviewed.
F 0657: The facility failed to review and revise the care plan for falls for Resident #2 after a fall incident.
F 0812: The facility failed to discard expired food items and properly label and date food in multiple kitchen and nourishment refrigerators.
F 0851: The facility failed to submit accurate payroll data regarding 24-hour licensed nurse coverage for 9 days reviewed in the first quarter of fiscal year 2024.
F 0883: The facility failed to follow policy and provide education or offer up-to-date pneumococcal vaccines to 5 of 5 residents reviewed for immunization status.
Report Facts
Days with inaccurate payroll data: 9
Residents reviewed for MDS assessment transmission: 9
Residents reviewed for care plans: 9
Residents reviewed for immunization status: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse #1 | Named in findings related to failure to transmit MDS assessments and late resubmission | |
| Director of Nursing | Named in interviews regarding MDS assessment transmission, care plan review, and immunization policy adherence | |
| Dining Services Director | Named in findings related to food labeling and storage deficiencies | |
| Administrator | Named in interviews regarding food safety and staffing data submission issues | |
| Infection Preventionist | Named in findings related to pneumococcal vaccine education and policy |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with Medicare and Medicaid regulations, specifically focusing on beneficiary protection notification and quality assurance processes.
Findings
The facility failed to provide the Centers for Medicare & Medicaid Services Notice of Medicare Non-Coverage Letter for 1 of 3 sampled residents, continuing a pattern of noncompliance from a previous survey. Additionally, the facility's quality assurance process failed to effectively monitor and sustain corrective actions from prior deficiencies.
Deficiencies (2)
F582: The facility failed to provide the CMS Notice of Medicare Non-Coverage Letter for 1 of 3 sampled residents reviewed for beneficiary protection notification.
F0867: The facility failed to implement, monitor, and revise the quality assurance action plan to sustain compliance with Medicaid/Medicare Coverage/Liability Notice requirements.
Report Facts
Residents sampled for beneficiary protection notification review: 3
Residents affected by deficiency F582: 1
Residents affected by deficiency F0867: 1
Previous recertification survey date: Oct 7, 2021
Viewing
Loading inspection reports...
