Inspection Reports for LiveWell @ Governors Club Cottages (2) (Chapel Hill)
11476 Club Dr, Chapel Hill, NC 27517, USA, NC, 27517
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
100% occupied
Based on a April 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Oct 23, 2025 | 102.5 | 2.5 | 0 | Annual Inspection | |
| May 16, 2023 | 100 | 2 | 2 | Annual Inspection | |
| Aug 25, 2021 | 102.5 | 2.5 | 0 | Annual Inspection | |
| Mar 4, 2019 | 103 | 3 | 0 | Re-Issued |
Inspection Report
Complaint Investigation
Deficiencies: 39
May 5, 2025
Visit Reason
State-compiled facility profile showing 15 inspections from 2022-02-07 to 2025-05-05 with complaint and citation history including enforcement actions and deficiency details.
Findings
The facility has multiple complaint-related citations primarily involving quality of care, resident rights, physical environment, and dietary services. Deficiencies range mostly at Level 2 severity with some Level 4 and Level 3 findings indicating immediate jeopardy and actual harm in isolated cases. Enforcement actions include fines totaling $23,500 from 2015 to 2025.
Complaint Details
Facility received 49 complaints from November 1, 2021 to October 31, 2025 with 49 complaint-related on-site inspections and 127 complaint-related citations during this period.
Severity Breakdown
Level 0: 2
Level 1: 2
Level 2: 49
Level 3: 1
Level 4: 2
Deficiencies (39)
| Description | Severity |
|---|---|
| Activities meet interest/needs each resident — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| ADL care provided for dependent residents — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Food procurement,store/prepare/serve-sanitary — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 4 |
| Grievances — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Nutrition/hydration status maintenance — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Nutritive value/appear, palatable/prefer temp — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Reporting of alleged violations — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Resident allergies, preferences, substitutes — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Resident rights/exercise of rights — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Resident/family group and response — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Responsibilities of providers; required notif — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 0 |
| Safe/clean/comfortable/homelike environment — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Tube feeding mgmt/restore eating skills — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Right to access/purchase copies of records — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 1 |
| Right to survey results/advocate agency info — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Respiratory/tracheostomy care and suctioning — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Pharmacy srvcs/procedures/pharmacist/records — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Free from abuse and neglect — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Free of accident hazards/supervision/devices — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 4 |
| Investigate/prevent/correct alleged violation — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| License/comply w/ fed/state/locl law/prof std — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Treatment/svcs to prevent/heal pressure ulcer — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 3 |
| Reporting - national health safety network — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Quality of care — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Reasonable accommodations needs/preferences — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Abuse, neglect, and exploitation training — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Infection control — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 0 |
| Infection prevention & control — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Essential equipment, safe operating condition — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Cooking facilities — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Develop ep plan, review and update annually — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 1 |
| Electrical equipment - testing and maintenanc — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Electrical systems - essential electric syste — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Emergency lighting — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Ep training and testing — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 1 |
| Fire drills — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Hazardous areas - enclosure — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Portable fire extinguishers — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Sprinkler system - maintenance and testing — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
Report Facts
Inspections on page: 15
Total citations: 61
Number of complaints: 49
Complaint-related citations: 127
Complaint-related on-site inspections: 49
Total fines: 23000
Total fines: 2500
Total fines: 25500
Plan of correction counts: 15
Inspection Report
Routine
Census: 6
Capacity: 6
Deficiencies: 3
Apr 3, 2024
Visit Reason
DHSR Construction Section conducted a Biennial Survey to ensure compliance with the 2005 Rules 10A NCAC 13G for Family Care Homes and the 2012 North Carolina State Building Code for Small Non-Ambulatory Care Facilities.
Findings
The survey identified deficiencies related to fire safety and building equipment maintenance, including inadequate heat detector coverage in attic compartments, a dropped sprinkler escutcheon plate exposing an opening, and unsecured oxygen tanks in a resident bedroom.
Deficiencies (3)
| Description |
|---|
| The attic in bedroom #1 had multiple compartments but only one compartment had a verified heat detector; documentation or installation of a secondary heat detector is required. |
| The sprinkler escutcheon plate dropped down from the ceiling near the medical room, exposing an opening that could allow the spread of smoke and heat. |
| Multiple oxygen tanks in bedroom #4 were not properly secured, posing a potential injury risk. |
Report Facts
Licensed capacity: 6
Census: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243354.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00243354; no violations were found.
Inspection Report
Annual Inspection
Deficiencies: 1
Apr 11, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility on April 11, 2023.
Findings
The facility failed to ensure that one of three sampled residents had completed the required two-step tuberculosis (TB) testing upon admission, as mandated by state regulations. Specifically, Resident #3 had only one documented negative TB skin test prior to admission, with no documentation of a second test.
Deficiencies (1)
| Description |
|---|
| Failure to ensure 1 of 3 sampled residents had completed tuberculosis testing upon admission in compliance with control measures. |
Report Facts
Sampled residents: 3
Residents with incomplete TB testing: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 9, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00197796.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint GA00197796 with no rule violations cited.
Inspection Report
Follow-Up
Deficiencies: 0
May 28, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 3/14/19 investigation.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 11, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00194966 regarding alleged resident abuse.
Findings
The investigation found that facility staff (Staff B) failed to report an allegation of resident abuse in a timely manner for one of four sampled residents (Resident #1). Staff C was alleged to have verbally abused Resident #1 and was terminated. Staff B and others were re-trained on the Abuse Reporting Act.
Complaint Details
Investigation of complaint #GA00194966 found that Staff B overheard Staff C threaten Resident #1 in mid-January 2019 but did not report it immediately. Staff C was terminated. Resident #1 denied being threatened. Staff B reported the incident to Staff A and again at a staff meeting on 2/22/19. Staff C denied the allegations.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to report an allegation of resident abuse to the Department in a timely manner for Resident #1. | D |
Report Facts
Date of investigation completion: Mar 14, 2019
Date of onsite visit: Mar 11, 2019
Number of sampled residents: 4
Date Staff B reported Staff C: Feb 22, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Failed to report abuse allegation in a timely manner; overheard Staff C threaten Resident #1 | |
| Staff C | Alleged to have verbally abused Resident #1; terminated; denied allegations | |
| Staff A | Was told by Staff B about the threat but took no action |
Inspection Report
Complaint Investigation
Census: 3
Deficiencies: 1
Feb 4, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint GA00194353, which began on 2019-01-30 with an onsite visit on 2019-02-04.
Findings
The facility failed to provide services commensurate with the needs of 3 residents, as evidenced by residents being left alone without staff supervision and behavioral issues documented in individual service plans. Staff was unaware when a visitor entered through the back door, indicating inadequate supervision.
Complaint Details
Investigation of complaint GA00194353 found that on 10/29/18, a visitor was let into the facility by Resident #3 and found three residents alone without staff present. Staff E was on the front porch and unaware of the visitor entering. Behavioral issues with residents were documented in their individual service plans.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide services commensurate with the needs of 3 residents, including inadequate supervision and failure to address behavioral support needs. | SS= D |
Report Facts
Residents present during inspection: 3
Investigation start date: Jan 30, 2019
Investigation end date: Feb 4, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Staff E was interviewed and stated being on the front porch talking to his/her niece and was unaware of visitor entering through back door. |
Inspection Report
Original Licensing
Deficiencies: 1
Oct 3, 2018
Visit Reason
The Adult Care Licensure Section conducted an initial survey of the facility on October 3, 2018.
Findings
The facility failed to ensure medication administration records were accurate and complete for one resident, including documentation of narcotic, sleeping aid, antacid, and pain medication administration. The medication administration record was not properly initialed after administration on one occasion, and the error was not detected during audits.
Deficiencies (1)
| Description |
|---|
| Medication administration records were not accurate and complete for Resident #1, with missing documentation of administration for multiple medications on 08/29/18 at 8:00pm. |
Report Facts
Date of medication orders: Aug 3, 2018
Date of resident FL-2: Jul 31, 2018
Date of medication administration error: Aug 29, 2018
Date of survey completion: Oct 3, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Interviewed regarding medication administration on 08/30/18 | |
| Administrator | Interviewed regarding medication administration documentation and audit process |
Inspection Report
Annual Inspection
Deficiencies: 1
Nov 8, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection and investigate complaints #GA00181754 and #GA00181838.
Findings
The facility failed to have a physician's written order every 180 days for the use of a medical protection device for 1 of 1 residents needing such a device. The last physician's order for the wheelchair was dated 04-06-2017, which was 215 days prior to the inspection.
Complaint Details
The inspection included investigation of complaints #GA00181754 and #GA00181838.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have a physician's written order every 180 days for the use of a medical protection device for 1 of 1 residents needing such a device. | E |
Report Facts
Days since last physician's order: 215
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 interviewed and stated unawareness of the requirement for a physician's order every 180 days. |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 7, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 08-03-2016 inspection.
Findings
No rule violations were cited as a result of this inspection.
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