Chapel Hill Nursing Center

In the surveyor’s words

From the most serious findings on record at Chapel Hill Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 16, 2025

  Based on the investigation of the facility reported incident, review of medical records and interview with facility staff, it was determined that the facility failed to follow the specified number of staff support needed when providing care for residents. This resulted in the resident falling out of the bed and suffering a left acute frontal subdural hematoma, which required surgery. This was evident for 1 (Resident #264) out of 9 residents reviewed for accidents during the Medicare/Medicaid recertification survey. […]

• No harm, potential for more than minimal, widespreadF812Mar 30, 2026

  Based on observation and interview it was determined the facility failed to ensure professional standards for food service safety was followed. This was evident for 1 of 1 facility kitchen, and 2 of 2 units observed during the facility's recertification survey. The findings include:During the surveyor's initial tour of the facility on 3/23/26 at 7:43 AM the surveyor observed an open cart sitting in the Unit 1 nursing hallway which contained a glass ice water dispenser with a rope handle sitting on the top tier of the cart. The second tier of the cart was observed to have a dirty food tray with dirty dishes and wilted lettuce with orange liquid present on it protruding out of the cart sitting directly next to an open sleeve of unused cup lids. […]

• No harm, potential for more than minimal, widespreadF812Jan 16, 2025

  Based on observations and interviews with the facility staff, it was determined that the dietary staff 1) Failed to maintain the temperature logs on the refrigerator and freezer, 2) failed to date and label foods stored in the refrigerator and freezer with expiration dates and, 3) failed to put on beard covers while handling the resident's food. These were identified during 2 out of 4 observations of kitchen food service operations during the recertification survey and has the potential to affect all residents. The findings include: 1) On 01/08/25 at 08:28 AM, during the initial tour of the kitchen, the surveyor observed that the temperature logs on the doors of the refrigerator (1 and 2) and freezers (1 and 2) were not charted from 01/04/2025 - 01/06/2025. […]

• No harm, potential for more than minimal, widespreadF943Jan 16, 2025

  Based on record review and staff interview, it was determined the facility failed to provide evidence that all nursing staff had received education on abuse, neglect, and exploitation training annually. This was evident for 6 (nurse #11, #28, #38, and Nurse Aides #35, #39, and #40) of 6 nursing staff training records reviewed during the recertification/complaint survey. The findings include: On 1/15/25 at 11:29 AM, the surveyor reviewed randomly selected six nursing staff ( nurse #11, #28, #38, and Nurse Aides #35, #39, and #40) employee files for their training records from 2022 to current. The review revealed that a Registered Nurse ( RN #11) was hired in June 2019, a Licensed Practical Nurse (LPN #28) was hired in January 2023, and LPN #38 was hired in May 2022. […]

• No harm, potential for more than minimal, patternF584Mar 30, 2026

  Based on observations, interviews, and record reviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment in good repair. This was evident for 2 of 2 Nursing units and 1 out of 1 dining area reviewed during the annual recertification survey and investigation of complaints; #2713655, #320969, and #320969.The findings include: 1. During the surveyor's initial tour of the facility on 3/23/26 at 7:43AM the surveyor observed that the supply of linens present on the nursing unit 1 hallway was low in quantity. On 3/23/26 at 2:06PM the surveyor conducted a review of Complaint #320969 which included a concern for delays in Resident incontinence care. […]