The Cedars of Chapel Hill

In the surveyor’s words

From the most serious findings on record at The Cedars of Chapel Hill, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF578Jun 4, 2024

  Based on records review, and staff interviews, the facility failed to include code status in the resident's record for 1 of 1 resident reviewed for Advance Directives (Resident #15). Findings included: Resident #15 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as moderately cognitively impaired. Care Plan dated 4/8/24 indicated the resident had no care plan for Advanced Directives. The quarterly MDS dated [DATE] revealed the assessment was still in progress. Assessment indicated Resident #15 was severely cognitively impaired. Review of physician's orders on 6/2/24, revealed there was no active order for code status in Resident #15's Electronic Health Record (EHR). […]

• No harm, potential for more than minimal, isolatedF638Jun 4, 2024

  Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the regulatory timeframe (14 days of the Assessment Reference Date (ARD), the last day of the look-back period) as specified in the Resident Assessment Instrument (RAI) manual for 1 of 1 residents reviewed for resident assessment (Resident #2) and 1 of 1 resident reviewed for completion of quarterly assessment (Resident # 15). Finding included. 1. Resident #2 was admitted to the facility on [DATE] Review of Resident #2's quarterly MDS assessments revealed the assessment had an Assessment Reference Date (ARD, the last day of the look-back period) of 4/3/24. The quarterly MDS dated [DATE] was in process and was incomplete. […]

• No harm, potential for minimal, patternF640Jun 4, 2024

  Based on record reviews and staff interviews, the facility failed to complete and transmit Discharge Minimum Data Set (MDS) assessments within the required time frame for 4 of 4 residents (Resident #14, Resident #1, Resident #5, and Resident #13) selected for Resident Assessments. Findings included: 1. Resident #14 was admitted on [DATE] The last MDS assessment completed and transmitted was an admission MDS assessment dated [DATE]. Review of the progress note by the Social Worker dated 5/19/24 revealed Resident #14 was moved to a non-certified bed in the facility on 5/15/24. […]