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 Signature Healthcare Of Chapel Hill during CMS and state inspections, most recent first.
Surveyors found that staff failed to remove expired medications and did not date open medications in both a medication refrigerator and a medication cart. Multiple open insulin pens, inhalers, and eye drops were observed without open dates, and an expired vial was not removed as required. Staff interviews confirmed that nurses were responsible for dating and checking medications, but these procedures were not consistently followed.
Expired fortified nutritional supplements were found stored in a nourishment kitchenette, with 18 packs expired on one date and 6 packs expired on another. Two residents receiving tube feeding could have been affected. The Central Supply staff, responsible for restocking and checking expiration dates, admitted to possibly overlooking expired items due to being busy. The DON and Administrator confirmed staff responsibilities for removing expired supplements.
Two residents were affected by deficiencies in environmental cleanliness and equipment safety. One resident's room had dried tube feeding residue on the floor and television monitor that remained uncleaned for several days, while another resident's bed control had exposed wires resting on the pillow. Housekeeping and maintenance routines failed to address these issues in a timely manner.
Several residents with diabetes had their insulin administration inaccurately documented in the MAR, with a Medication Aide signing as the provider despite not being authorized or actually administering the insulin. Interviews confirmed that licensed nursing staff gave the insulin, but the Medication Aide either signed the MAR after witnessing the administration or was prompted by the electronic system to complete the documentation, leading to inaccurate records.
The facility failed to follow CDC recommendations for COVID-19 vaccination for five residents. The medical records showed no information about being offered the 2023-2024 vaccine or receiving education related to it. Interviews confirmed that residents were not informed or educated about the new vaccine, despite expressing interest. The DON and Administrator were unaware of the new vaccination updates.
The facility failed to report an allegation of abuse involving a resident who claimed to have been pushed down into her bed to law enforcement or APS. Additionally, the facility did not report an allegation of misappropriation of resident funds to APS. The facility's policy lacked procedures for reporting such allegations to APS, contributing to these deficiencies.
The facility's QAPI committee failed to maintain effective procedures and monitor interventions, leading to repeated deficiencies in assessing residents' ability to self-administer medications. This issue was identified for a cognitively impaired resident who was not assessed for the ability to self-administer eye drops kept at the bedside.
The facility failed to include a cognitively intact resident and her responsible party (RP) in the care planning process. Despite expectations and procedures to involve residents and their RPs, there was no documentation or evidence that Resident #71 or her RP were invited to or participated in care plan meetings, leading to the identified deficiency.
A facility failed to assess a resident with glaucoma and dry eyes syndrome for self-administration of eye drops. Despite no physician's order, the resident had eye drops at her bedside and used them independently. The facility's protocol for self-administration, including a formal assessment and physician's order, was not followed.
A resident, who was cognitively intact, had her social security check deposits redirected to the facility's account without her permission. The Business Office Manager applied for the facility to become the resident's representative payee without obtaining written consent and did not offer the resident the opportunity to manage her own funds. The facility Administrator confirmed that alert and oriented residents should manage their personal funds, highlighting a violation of the resident's rights.
The facility failed to arrange podiatry services and provide adequate toenail care for a resident with left hemiplegia and hemiparesis following a stroke. Despite the resident's reports and observations of long, thick, and curling toenails, no action was taken, and the resident was not referred to a podiatrist as needed.
Failure to Remove Expired Medications and Date Opened Medications
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications and failed to date open medications in both a medication storage refrigerator and a medication cart. In the Blue Hall medication storage refrigerator, an open glargine insulin pen was found without an open date, despite manufacturer instructions to discard after 28 days of use. Additionally, an open vial of tuberculin purified protein derivative was found with an open date exceeding the 30-day discard period. Unit Manager #1 confirmed these findings and acknowledged that nurses were responsible for dating and checking medications for expiration, but the expired medication had not been removed as required. On the Red Hall medication cart, several open medications, including insulin pens, inhalation powders, and various ophthalmic solutions, were found without open dates. These medications all had manufacturer recommendations for timely disposal after opening, which were not followed. Medication Aide #2 and Unit Manager #2 confirmed the lack of open dates and indicated there was no specific staff member assigned to check the medication cart for compliance. The DON stated that all nurses were responsible for dating and checking medications, but the required procedures were not consistently followed.
Expired Nutritional Supplements Not Removed from Nourishment Room
Penalty
Summary
Expired fortified nutritional supplements were found stored in the nourishment kitchenette on the Blue side hallway, with 18 packs expired on one date and 6 packs expired on another. These expired items were observed during a walkthrough with the Dietary Manager. The facility had two residents receiving tube feeding who could have been affected by the presence of expired supplements. Interviews with staff revealed that the Central Supply staff was responsible for restocking and checking expiration dates of nutritional supplements in the nourishment kitchenettes. The Central Supply staff stated she checked expiration dates weekly but admitted she may have overlooked some items due to being busy. The DON confirmed that the Central Supply staff was responsible for ordering, restocking, and removing expired supplements, and the Administrator expected timely removal of expired items.
Failure to Maintain Cleanliness and Safe Equipment in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and staff interviews. In one instance, a large brown semi-solid puddle of dried fluid, identified as tube feeding, was found trailing towards the window in a resident's room, with the floor remaining sticky and a brown dried substance present on the bedside television monitor and its controls. These conditions persisted over several days, despite regular housekeeping routines. Housekeeping staff reported that they were not permitted to clean up bodily fluids and only addressed spills such as water, juice, or food, while the Director of Housekeeping confirmed that tube feeding spills were difficult to clean once dried and noted that the spill had been left over the weekend. The brown substance on the television monitor was not previously identified or cleaned by staff. In another instance, the bed control for a resident's bed was observed with the outer insulation casing stripped away, leaving three individual wires exposed and resting on the resident's pillow while the resident was in bed. The Maintenance Director stated that bed controls were checked monthly and that staff were expected to report any issues for repair. Documentation showed that the bed controls had been inspected the previous month, with checks for proper operation and for any cracked or frayed wires. However, the exposed wiring was not identified or addressed prior to the surveyor's observation.
Inaccurate MAR Documentation for Insulin Administration
Penalty
Summary
The facility failed to maintain accurate Medication Administration Records (MARs) for several residents receiving insulin, resulting in documentation that incorrectly identified Medication Aide (MA) #2 as the individual administering insulin. According to the report, MA #2 was not permitted to administer insulin as it was outside her scope of practice. However, the MARs for three residents with diabetes showed that insulin doses were signed out under MA #2’s name, even though licensed nursing staff actually administered the medication. This practice was confirmed through interviews with both the MA and supervising nurses, who stated that the MA would sign out the insulin after witnessing the nurse administer it, or that the electronic MAR system would prompt the MA to complete the documentation after entering blood sugar values. For one resident with moderate cognitive impairment and physician orders for both scheduled and sliding scale insulin, the MAR reflected multiple instances where insulin administration was signed out by MA #2. Interviews with the resident, MA #2, and supervising nurses confirmed that the MA did not administer the insulin, but signed for it after the nurse gave the injection. Similar documentation discrepancies were found for two other residents with diabetes, one of whom was cognitively intact and confirmed that only nurses administered his insulin. In these cases, the MARs again showed MA #2 as the person administering insulin, despite her not being authorized or actually performing the task. Staff interviews, including those with the Director of Nursing and a unit manager, confirmed that Medication Aides were not allowed to administer insulin and that a supervising nurse was always responsible for giving insulin to residents. The documentation errors occurred because the MA, while entering blood sugar readings or witnessing the administration, would sign out the insulin on the MAR, or the electronic system would default to the MA’s initials. This resulted in inaccurate medical records that did not reflect the actual provider of care, affecting at least three residents whose records were reviewed.
Failure to Follow CDC COVID-19 Vaccination Recommendations
Penalty
Summary
The facility failed to follow the current CDC recommendations for COVID-19 vaccination for five residents. The facility's infection control vaccination program, revised on 9/17/23, stated that it would follow all governing regulations and official COVID-19 recommendations. However, the medical records of five residents (Resident #53, Resident #4, Resident #43, Resident #6, and Resident #46) showed no information about being offered the 2023-2024 COVID-19 vaccine or receiving education related to the vaccine. Interviews with these residents confirmed that they were not informed or educated about the new vaccine, despite expressing interest in receiving it. The Director of Nursing (DON), who was also the Infection Preventionist, stated that she was aware of the new 2023-2024 COVID-19 vaccine and believed that residents were offered the vaccine. However, upon checking, she found no documentation in the residents' medical records related to the new vaccine. The Administrator also stated that he was not aware of the new vaccination and that the corporate office did not send the CDC updates. This lack of communication and documentation led to the deficiency in following CDC recommendations for COVID-19 vaccination.
Failure to Report Abuse and Misappropriation of Property
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who claimed to have been pushed down into her bed. The incident occurred on 11/12/23 but was not reported to the facility staff until 11/13/23. Although the facility reported the allegation to the state agency within 2 hours, they did not notify law enforcement or adult protective services (APS). The Administrator believed he had reported the incident to law enforcement but did not report it to APS, and law enforcement confirmed there was no record of the incident being reported by the facility or the Administrator. Additionally, the facility failed to report an allegation of misappropriation of resident funds. A resident reported that his bank card was stolen, and while the facility notified law enforcement, they did not notify APS. The Administrator confirmed that he reported the incident to law enforcement and the ombudsman but did not report it to APS. The facility's policy did not include procedures for reporting allegations of abuse or misappropriation of resident property to APS, contributing to these deficiencies.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain effective procedures and monitor interventions following multiple surveys, including a recertification and complaint investigation survey. This deficiency was specifically noted in the area of Resident Self-Administer Medication, where the facility did not assess if a cognitively impaired resident could self-administer eye drops kept at the bedside. This issue was identified for one resident reviewed for self-administration of medication. During previous complaint investigation surveys, the facility similarly failed to assess residents' ability to self-administer medications. These failures were documented in surveys conducted on 11/03/23 and 06/23/22. The Administrator indicated that the QAPI committee, which includes various key staff members, meets quarterly or as needed to address areas of concern identified through various means. However, the continued deficiencies indicate a pattern of the facility's inability to sustain an effective QAPI program.
Failure to Include Resident and Responsible Party in Care Planning
Penalty
Summary
The facility failed to include a cognitively intact resident and her responsible party (RP) in the care planning process. Resident #71, who was admitted to the facility, had a care plan last revised on 3/20/24. However, the care conference notes from 12/14/23 and 3/7/24 did not show evidence that Resident #71 or her RP were invited or involved in these meetings. Interviews with Resident #71 and her RP confirmed that they were not contacted or invited to participate in the care planning meetings. The SSD and MDS Nurse also could not provide documentation or reasons for their absence, and no refusals were recorded in the resident's care plan. The SSD stated that she usually invited residents and their representatives to care plan meetings but could not recall why Resident #71 and her RP were not included. The Director of Nursing emphasized that residents and their RPs should always be encouraged to participate in care planning. The Administrator expected all residents to be involved in their care, and any contact with the resident or RP should be documented. Despite these expectations, there was no documentation of attempts to include Resident #71 or her RP in the care planning process, leading to the identified deficiency.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess whether a cognitively intact resident with glaucoma and dry eyes syndrome could self-administer eye drops. Despite the absence of a physician's order for self-administration, the resident had both prescription and over-the-counter eye drops at her bedside and reported administering them herself. The resident's care plan did not include medication self-administration, and no assessment was completed to determine her capability to self-administer medications independently. On 4/7/24, an agency nurse left the eye drops at the resident's bedside, instructing her on their use. The resident subsequently used the eye drops without supervision. The interim Unit Manager and the Director of Nursing confirmed that the facility's protocol for self-administration, which includes a formal assessment and a physician's order, was not followed. The agency nurse responsible for leaving the medications was unavailable for comment during the survey.
Failure to Honor Resident's Right to Manage Personal Funds
Penalty
Summary
The facility failed to honor a resident's right to manage her personal funds. Resident #40, who was admitted with diagnoses including a contracture to the right knee and type 2 diabetes, was found to be cognitively intact based on an Admission Minimum Data Set assessment. During an interview, Resident #40 revealed that the Business Office Manager had changed the banking location of her social security check deposits from her private account to the facility's account without her permission. The Business Office Manager confirmed that she applied for the facility to become Resident #40's representative payee without obtaining written permission from the resident. She also did not offer Resident #40 the opportunity to manage her own funds, assuming the money needed to come directly to the facility because it was owed to them. Additionally, the Business Office Manager did not keep a copy of the representative payee application and did not recall any physician deeming Resident #40 as cognitively impaired or unable to manage her personal funds. The facility Administrator confirmed that alert and oriented residents should be given the opportunity to manage their personal funds. This indicates a clear violation of the resident's rights, as the facility did not follow proper procedures to ensure Resident #40's autonomy in managing her finances. The Business Office Manager's actions were not aligned with the resident's cognitive status and rights, leading to the deficiency noted in the report.
Failure to Provide Adequate Toenail Care
Penalty
Summary
The facility failed to arrange podiatry services and provide adequate toenail care for Resident #70, who was admitted with diagnoses including left hemiplegia and hemiparesis following a stroke. Despite being cognitively intact and requiring supervision for showers, Resident #70 reported that his toenails had not been cut and he had an ingrown nail that needed attention. Observations confirmed that his toenails were long, thick, grayish, and curling downwards, although no redness or inflammation was noted. The resident had reported this issue to the Unit Manager two months prior, but no action was taken, and the Unit Manager was no longer employed at the facility, making follow-up impossible. Nurse Aide #2, who assisted Resident #70 with showers and personal hygiene, stated that she attempted to cut his toenails but found them too thick and lacked the proper tools. The Social Services Director, responsible for scheduling podiatry appointments, indicated that the podiatrist visited every three months and that residents were referred based on specific criteria, but she could not confirm when Resident #70 was last seen by podiatry. The Director of Nursing provided records showing that the resident's nails were trimmed in December, but no recent records were found. The Administrator emphasized that residents' nails should be well-groomed and referred to a podiatrist if necessary, but this was not done for Resident #70.
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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.
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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) |
|---|---|---|---|---|
| Parkview Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 3 | 0 |
| The Cedars Of Chapel Hill | 2.1 mi | ★★★★★ | 0 | 0 |
| Carol Woods | 2.2 mi | ★★★★★ | 0 | 0 |
| Pruitthealth-carolina Point | 4.4 mi | ★★★★★ | 3 | 0 |
| The Forest At Duke Inc | 5.4 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.