SIGNATURE HEALTHCARE OF CHAPEL HILL

Nursing Home Inspector

1602 E FRANKLIN STREET
CHAPEL HILL, NC 27514
Orange County
Phone: 919-967-1418
Provider Number: 345225
Last Inspection: 04/26/2017

About the Nursing Home

Number of Beds: 108
Number of Residents: 85
Beds Available: 23
Percent Occupancy: 79%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

56

Facility
27

County
14

NC
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

56

2017
16

2016
0

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

4/26/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 6/14/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Immediate 5 6/14/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 6/14/2017
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 6/14/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/14/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 6/14/2017
 
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Immediate 5 6/14/2017
 
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Immediate 5 6/14/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 6/29/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 6/14/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Immediate 5 6/14/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Isolated : Minimal 3 6/14/2017
 
Failed To: Dispose of garbage and refuse properly. Widespread : Potential 4 6/14/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/14/2017
 

5/20/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 6/13/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 6/13/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 6/13/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 6/13/2016
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Isolated : Minimal 3 6/27/2016
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

6/14/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Potential 4 6/29/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 6/29/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 6/29/2017
 

2/2/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 2/24/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 2/24/2017
 

1/22/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 2/19/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 2/19/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NC State Avg
Number of Residents 85 60.00 84.96
Registered Nurses 0.70 1.11 0.72
Licensed Practical / Vocational Nurses 0.71 0.84 0.87
Certified Nursing Assistants 1.66 2.54 2.33
Total Staff Hours 3.07 4.49 3.91

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NC State Avg%
of high risk long-stay residents with pressure ulcers 3 3 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 92 97 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 93 97 93
of long-stay residents experiencing one or more falls with major injury 3 2 3
of long-stay residents who have depressive symptoms 0 4 2
of long-stay residents who lose too much weight 13 15 8
of long-stay residents who received an antianxiety or hypnotic medication 22 13 29
of long-stay residents who received an antipsychotic medication 17 9 13
of long-stay residents who self-report moderate to severe pain 6 3 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 21 20 23
of long-stay residents whose need for help with daily activities has increased 21 18 18
of long-stay residents with a catheter inserted and left in their bladder 3 4 1
of long-stay residents with a urinary tract infection 4 6 4
of low risk long-stay residents who lose control of their bowels or bladder 68 73 55
of short-stay residents assessed and appropriately given the pneumococcal vaccine 54 84 83
of short-stay residents who had an outpatient emergency department visit 14 8 13
of short-stay residents who made improvements in function 51 66 64
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 27 14 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 55 84 81
of short-stay residents who were rehospitalized after a nursing home admission 30 18 20
of short-stay residents who were successfully discharged to the community 48 64 55
of short-stay residents with pressure ulcers that are new or worsened 0 1 0