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Litchford Falls Health and Rehabilitation Center
8200 Litchford Road, Raleigh, NC 27615 · CMS Certification Number (CCN) 345499
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 22 in the last 3 inspection cycles (3 immediate jeopardy, 0 actual harm, 17 from complaints)
- Fire safety citations
- 28
- Fines (last 3 years)
- 2 fines, total $181,873
- Payment denials
- 0
- Most recent standard inspection
- July 10, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.9 | 3 |
| Health inspections | ★☆☆☆☆ 1 of 5 | 2.9 | 2.8 |
| Staffing | ★★☆☆☆ 2 of 5 | 2.7 | 2.9 |
| Quality measures | ★★☆☆☆ 2 of 5 | 3.3 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★☆☆☆☆ 1 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | July 10, 2026 | 6 | 3 | 4 |
| Cycle 2 | May 8, 2025 | 16 | 5 | 13 |
CMS weighted health inspection score: 75.75 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
22 health citations across 7 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 10, 2026: 3 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| C | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Standard | No revisit needed Corrected 07/27/2026 |
| E | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 07/27/2026 |
| D | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/27/2026 |
January 8, 2026: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/05/2026 |
| D | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/05/2026 |
| D | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/05/2026 |
May 8, 2025: 5 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/05/2025 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 06/05/2025 |
| D | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/05/2025 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/05/2025 |
| E | F-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. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 06/05/2025 |
February 17, 2025: 5 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/06/2025 |
| D | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/06/2025 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/06/2025 |
| D | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/06/2025 |
| D | F-0578 | 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. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/06/2025 |
December 17, 2024: 4 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/16/2025 |
| J | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/16/2025 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/16/2025 |
| J | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 01/17/2025 |
March 21, 2024: 1 citation (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-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. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/18/2024 |
September 28, 2023: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Past Non-Compliance Corrected 08/30/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
28 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 05/08/2025 | D | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | D | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | D | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | D | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | D | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | E | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | E | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | D | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | D | K-0271 | Have exits that are accessible at all times. Egress Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | D | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 05/08/2025 | D | K-0161 | Use approved construction type or materials. Construction Deficiencies | Deficient, Provider has date of correction Corrected 07/15/2025 |
| 03/21/2024 | D | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/31/2024 |
| 03/21/2024 | D | K-0911 | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/31/2024 |
| 03/21/2024 | D | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies | Deficient, Provider has date of correction Corrected 05/31/2024 |
| 03/21/2024 | D | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/31/2024 |
| 03/21/2024 | D | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies | Deficient, Provider has date of correction Corrected 05/31/2024 |
| 03/21/2024 | D | K-0271 | Have exits that are accessible at all times. Egress Deficiencies | Deficient, Provider has date of correction Corrected 05/31/2024 |
| 03/21/2024 | D | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies | Deficient, Provider has date of correction Corrected 05/31/2024 |
| 03/21/2024 | D | K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. Construction Deficiencies | Deficient, Provider has date of correction Corrected 05/31/2024 |
| 12/09/2022 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 02/19/2023 |
| 12/09/2022 | D | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 02/19/2023 |
| 12/09/2022 | D | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 02/19/2023 |
| 12/09/2022 | F | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/19/2023 |
| 12/09/2022 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/19/2023 |
| 12/09/2022 | D | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/19/2023 |
| 12/09/2022 | D | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/19/2023 |
| 12/09/2022 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/19/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| December 17, 2024 | Fine | $177,911 | — |
| September 28, 2023 | Fine | $3,962 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.55 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.58 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 0.89 | Not published | Not published |
| Nurse aide hours per resident per day | 2.08 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.33 | Not published | Not published |
| RN hours per resident per day, weekends | 0.52 | Not published | Not published |
| Total nursing staff turnover (%) | 50.6 | 49 | 45.8 |
| Registered nurse turnover (%) | 60 | Not published | Not published |
| Administrators who have left | 2 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Litchford Operator LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Lifeworks Rehab (64 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 90
- Average residents per day
- 86.4
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- March 2, 2000
- County/parish
- Wake
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
51 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| LITCHFORD HOLDINGS I LLC | DIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| 8200 LITCHFIELD ROAD LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BRIDGEWATER NC HOLDINGS LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CZ FAMILY TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| HL FAMILY TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| HSHC 2024 FAMILY TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| IB MIMI 2022 FAMILY GRANTOR TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| IB MIMI 2022 FAMILY TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| JK 2022 GRANTOR FAMILY TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MEDICAL FACILITIES OF AMERICA ADMINISTRATIVE CONSULTING SERVICES LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MILANO FAMILY HOLDINGS LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ML MILANO 2022 FAMILY GRANTOR TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ML MILANO 2022 FAMILY TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TJ FAMILY TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TOL OPCO INVESTCO LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| UH CAROLINA LF SNF OPERATIONS HOLDINGS LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| UNIVERSAL OPERATIONS HOLDINGS LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| WILL FAMILY 2016 TRUST | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BERG, TABITHA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BRYANT -LEVANT, KAREN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| RICHARDS, LINDA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SHAYO, JULIUS | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BRYANT -LEVANT, KAREN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KONDURU, RAMESH | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SHAYO, JULIUS | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HSHC 2024 FAMILY TRUST | TRUSTEE OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BURTON, NOAH | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ELLENBOGEN, MOSS | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| RUBIN, ELIEZER | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WEISS, HILLEL | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| 8200 LITCHFIELD ROAD LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ACS PRO GLOBAL SOLUTIONS | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BRIDGEWATER NC HOLDINGS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CYOP CYBER SECURITY LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| DIGACORE CONSULTING | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| HEALTHCARE SERVICES GROUP INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| IB MIMI 2022 FAMILY GRANTOR TRUST | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| IB MIMI 2022 FAMILY TRUST | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LITCHFORD HOLDINGS I LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LIVE WELL PLUS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MEDICAL FACILITIES OF AMERICA ADMINISTRATIVE CONSULTING SERVICES LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MFA HERITAGE CONSULTING LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MILANO FAMILY HOLDINGS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ML MILANO 2022 FAMILY GRANTOR TRUST | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ML MILANO 2022 FAMILY TRUST | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MOZART HOLDINGS, LP | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TURNING POINT CONSULTING | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BRYANT -LEVANT, KAREN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BURTON, NOAH | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ELLENBOGEN, MOSS | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KONDURU, RAMESH | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Litchford Falls Health and Rehabilitation Center. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.