Litchford Falls Health and Rehabilitation Center
8200 Litchford Road, Raleigh, NC 27615 · Wake County · 90 certified beds · avg 86 residents/day · certified since Mar 2, 2000
Part of chain: LIFEWORKS REHAB (64 facilities, chain avg rating 2.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Dec 17, 2024 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 17, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 17, 2024 · F-0756 · triggered by a complaint
The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Why it matters: Skipped pharmacist reviews allow unnecessary drugs, wrong doses, and harmful interactions to go undetected.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 16, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 17, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 16, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (19)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| May 8, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| May 8, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 8, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 8, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| May 8, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 17, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Feb 17, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Feb 17, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 17, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 17, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Dec 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint |
| Dec 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 17, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Sep 28, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (1 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 5 | 3 | J ▲ |
| 2025 | 10 | 0 | E |
| 2026 | 3 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $181,873.
| Date | Type | Amount / length |
|---|---|---|
| Dec 17, 2024 | Fine | $177,911 |
| Sep 28, 2023 | Fine | $3,962 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Carolina avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.29 | 4.01 | 3.95 | bottom 19% in North Carolina; bottom 26% in the U.S. |
| Registered Nurse hours | 0.54 | 0.64 | 0.69 | top 48% in North Carolina; bottom 44% in the U.S. |
| Weekend total nurse staffing | 3.08 | 3.56 | 3.50 | bottom 36% in North Carolina; bottom 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.52 | 0.41 | 0.48 | top 22% in North Carolina; top 31% in the U.S. |
| Total nursing staff turnover (%) | 50.6 | 49.0 | 45.8 | bottom 46% in North Carolina; bottom 35% in the U.S. |
| RN turnover (%) | 60.0 | 45.7 | 42.9 | bottom 30% in North Carolina; bottom 22% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.55, RN 0.58, weekend 3.33. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| 8200 Litchfield Road LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| Bridgewater NC Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| CZ Family Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| HL Family Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| HSHC 2024 Family Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| Ib Mimi 2022 Family Grantor Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| Ib Mimi 2022 Family Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| JK 2022 Grantor Family Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| Litchford Holdings I LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| Medical Facilities of America Administrative Consulting Services LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| Milano Family Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| ML Milano 2022 Family Grantor Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| ML Milano 2022 Family Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| TJ Family Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| Tol Opco Investco LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2025 |
| Uh Carolina LF SNF Operations Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| Universal Operations Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| Will Family 2016 Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/01/2024 |
| 8200 Litchfield Road LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2024 |
| Acs Pro Global Solutions | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Perry Creek Health and Rehabilitation Center | 2.6 mi | Raleigh, NC | ★☆☆☆☆ | 1/5 | |
| The Rosewood Health Center | 3.2 mi | Raleigh, NC | ★★★★★ | 4/5 | |
| The Cardinal at North Hills | 4.2 mi | Raleigh, NC | ★★★☆☆ | 4/5 | |
| Hillcrest Raleigh at Crabtree Valley | 6.0 mi | Raleigh, NC | ★★★★☆ | 4/5 | |
| Tower Nursing and Rehabilitation Center | 6.2 mi | Raleigh, NC | ★★☆☆☆ | 2/5 | |
| Bloomsbury at Hayes Barton Place | 6.2 mi | Raleigh, NC | —/5 | ||
| Raleigh Rehabilitation Center | 7.0 mi | Raleigh, NC | ★★★☆☆ | 3/5 | |
| Sunnybrook Rehabilitation Center | 7.2 mi | Raleigh, NC | ★☆☆☆☆ | 1/5 | |
| Capital Nursing and Rehabilitation Center | 7.3 mi | Raleigh, NC | ★★★★☆ | 4/5 | |
| Rex Rehab & Nursing Care Center | 7.5 mi | Raleigh, NC | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 345499.