Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carol Woods during CMS and state inspections, most recent first.
The facility failed to submit accurate payroll data to CMS regarding 24-hour licensed nurse coverage for nine days in the first quarter of fiscal year 2024. The PBJ report indicated a lack of coverage, but a review of staffing records showed 24-hour coverage was maintained. The Administrator confirmed the presence of licensed nursing staff, suggesting an error in data submission.
The facility failed to manage food storage and labeling, with expired and unlabeled items found in the main kitchen, building 4 kitchen, and nourishment room refrigerators. The Dining Services Director cited staff absences and new, untrained staff as reasons for the oversight. The Administrator acknowledged the issue and expected adherence to labeling policies.
The facility did not follow its policy on pneumococcal vaccination, failing to educate and offer the updated PCV20 vaccine to five residents. Despite having received previous vaccines, residents and their representatives were unaware of the new vaccine, and there was no documentation of education provided. The Infection Preventionist misunderstood the need for further vaccination, contributing to the deficiency.
The facility failed to transmit MDS assessments to CMS and QIES ASAP systems within required timeframes for two residents. A resident's discharge assessment was not accepted by CMS despite being marked as transmitted, and another resident's 5-day assessment was submitted late. The MDS Nurse cited being behind due to time off, and the DON could not explain the delays.
A resident with cerebral infarction and unsteadiness of feet had an outdated falls care plan that was not revised after a fall occurred. Despite cognitive impairment and a fall on record, the care plan was not updated since its last revision. Interviews with staff confirmed the oversight.
Inaccurate Payroll Data Submission for Licensed Nurse Coverage
Penalty
Summary
The facility failed to submit accurate payroll data to the Centers for Medicare and Medicaid Services (CMS) regarding 24-hour licensed nurse coverage for nine specific days in the first quarter of fiscal year 2024. The Payroll Based Journal (PBJ) report indicated a lack of 24-hour licensed nursing coverage on these days. However, a review of posted nurse staffing, nurse schedules, and nursing staff timecards for the specified days revealed that there was indeed 24-hour licensed nursing coverage. During an interview, the Administrator confirmed that licensed nursing staff were present on those days, suggesting that the office may have submitted the information incorrectly.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to properly manage food storage and labeling in both the main kitchen and building 4 kitchen, as well as in nourishment room refrigerators. During an initial tour, surveyors observed expired and unlabeled food items in the walk-in and reach-in coolers of the main kitchen and building 4 kitchen. Specific items included an opened bag of flour tortillas, a tray of mushrooms, a block of cheese, and various jars of dressings without proper labeling or with expired dates. Additionally, in building 4, an open carton of milk, shredded cheese, lettuce, and turkey slices were found without proper labeling or with expired dates. In the nourishment room refrigerators, an opened lemonade bottle and cottage cheese cups were found without proper dates. Interviews with the Dining Services Director revealed that the responsibility for checking labels and expiration dates in the main kitchen fell to the Master and Sous Chefs, who were supposed to perform these checks twice daily. However, due to staff absences and new, untrained staff, these checks were not completed. The Kitchen Manager, who was also new, was responsible for checking food items in building 4 and the nourishment refrigerators. The Administrator acknowledged awareness of the issue with unlabeled and misdated food items and expressed an expectation for staff to adhere to the facility's policy on labeling and storing food items.
Failure to Offer Updated Pneumococcal Vaccine
Penalty
Summary
The facility failed to adhere to its policy on pneumococcal vaccination, as evidenced by the lack of education and offering of the updated PCV20 vaccine to five residents. These residents, who were reviewed for immunization status, had received previous pneumococcal vaccines (PPSV23 and PCV13) but were not informed about the benefits and potential side effects of the newer PCV20 vaccine. Interviews with residents and their representatives revealed that they were not aware of the updated vaccine, and there was no documentation in their medical records indicating that such education had been provided. The facility's Infection Preventionist was under the impression that no further pneumococcal vaccines were needed after the administration of PPSV23, indicating a gap in following current CDC guidelines. This misunderstanding contributed to the failure to offer the PCV20 vaccine. The Director of Nursing expected staff to follow the facility's policy and current guidelines, but the deficiency suggests a lapse in communication and adherence to these standards.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) database and the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required timeframes for two residents. Resident #1's discharge MDS assessment, completed on March 8, 2024, was not accepted by the CMS database as of June 5, 2024, despite the facility's electronic medical record indicating it had been transmitted. MDS Nurse #1, responsible for the assessment, was unsure why it was not transmitted and accepted correctly, citing being behind due to being off work in January 2024. The Director of Nursing was also unable to explain why the assessment was not confirmed as transmitted and accepted. Resident #16's 5-day assessment, with an Assessment Reference Date (ARD) of January 18, 2024, was completed on February 1, 2024, but was not submitted to the QIES ASAP system until March 13, 2024. MDS Nurse #1 indicated that the assessment was initially rejected and had to be resubmitted, but she did not know why the submission was delayed. The Director of Nursing reiterated the expectation that all assessments should be completed and submitted within the required timeframes, but could not provide a reason for the delay in transmission.
Failure to Update Falls Care Plan
Penalty
Summary
The facility failed to review and revise the care plan for a resident in the area of falls. The resident was admitted with diagnoses including cerebral infarction and unsteadiness of feet, and had an active care plan initiated on 1/5/22, which was last updated on 10/24/23. Despite a fall occurring on 4/2/24, where the resident attempted to go to the bathroom without assistance, the care plan was not updated to reflect this incident. The resident's most recent quarterly MDS assessment indicated cognitive impairment and no falls since admission, yet the care plan remained unchanged. Interviews with the MDS Nurse and the Director of Nursing confirmed that the oversight occurred, and the care plan should have been reviewed and revised following the fall.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 63 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chapel Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Signature Healthcare Of Chapel Hill | 2.2 mi | ★★★★★ | 0 | 0 |
| Parkview Health And Rehabilitation Center | 2.3 mi | ★★★★★ | 3 | 0 |
| Pruitthealth-carolina Point | 3.2 mi | ★★★★★ | 3 | 0 |
| The Cedars Of Chapel Hill | 4.2 mi | ★★★★★ | 0 | 0 |
| The Forest At Duke Inc | 5.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.