Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Cedars Of Chapel Hill during CMS and state inspections, most recent first.
A facility failed to document a resident's DNR/DNI code status in their medical records. Despite the resident being admitted with a DNR/DNI status from the hospital, the electronic health record and paper chart lacked an active order for code status. Staff interviews revealed communication gaps, with the admitting nurse not discussing the code status with the physician, and the Social Worker unable to recall specifics about the resident's preferences. The Physician and DON noted that the admitting nurse was responsible for verifying the code status, which was not completed.
The facility failed to complete quarterly MDS assessments within the required timeframe for two residents. One resident's assessment was incomplete and unsigned 60 days after the ARD, while another's was incomplete 27 days after the ARD. The issue arose due to oversight by previous remote MDS staff and was identified in January, with a plan of correction discussed in a QA meeting.
The facility failed to complete and transmit Discharge MDS assessments within the required time frame for four residents. A resident was moved to a non-certified bed, and the discharge MDS assessment was incomplete. Another resident was discharged home and later admitted to a non-certified bed, but the assessment was missed. Two residents had completed assessments that were not transmitted. The MDS Nurse, hired in April, was addressing the backlog of incomplete assessments.
Failure to Document Code Status in Resident's Medical Records
Penalty
Summary
The facility failed to include the code status in the medical records of a resident who was admitted with a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status from the discharging hospital. Upon review, it was found that the resident's electronic health record and paper chart did not contain an active order for code status. The resident was assessed as moderately cognitively impaired upon admission and later as severely cognitively impaired. The care plan did not include advanced directives, and the quarterly Minimum Data Set (MDS) assessment was still in progress. Interviews with staff revealed a lack of communication and verification regarding the resident's code status. Nurse #1 indicated that the code status was marked on the paper chart with a red sticker for DNR, but no such sticker was present for full code status. Nurse #2, the admitting nurse, stated that she did not discuss the code status with the physician, only the discharge medication. The Social Worker mentioned discussing advance directives with the resident or their representative but did not recall specifics about this resident. The Physician and Director of Nursing (DON) both indicated that the admitting nurse was responsible for discussing and verifying the code status with the physician, but this was not done, leading to the absence of a verified order in the resident's records.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the regulatory timeframe for two residents. Resident #2's quarterly MDS assessment, with an Assessment Reference Date (ARD) of 4/3/24, was incomplete and unsigned by the RN Assessment Coordinator 60 days after the ARD. The MDS Nurse, hired on 4/1/24, indicated that some assessments were missed or incomplete due to the previous remote MDS staff's oversight. Similarly, Resident #15's quarterly MDS assessment, with an ARD of 5/7/24, was incomplete and unsigned 27 days after the ARD. The MDS Nurse acknowledged the oversight and stated that assessments should be completed within 7 to 14 days from the ARD. The Director of Nursing (DON) explained that the previous MDS staff was let go in January 2024 due to untimely completion of assessments, and a consulting company was used until a new MDS staff was hired in April 2024. The consultant staff also failed to complete assessments timely. The facility identified the issue in January 2024 and drafted a plan of correction, which could only be implemented after hiring the new MDS staff. The DON monitored the completion of assessments using the Electronic Medical Record (EMR) system and aimed for completion by June 30th. The Administrator confirmed that the plan of correction was discussed in the Quality Assurance (QA) meeting in May 2024, with a completion date set for June 30th.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit Discharge Minimum Data Set (MDS) assessments within the required time frame for four residents. Resident #14 was moved to a non-certified bed, and the discharge MDS assessment was incomplete and overlooked. Resident #1 was discharged home and later admitted to a non-certified bed, but the discharge MDS assessment was missed and incomplete. Resident #5 had a completed discharge MDS assessment that was not transmitted, and Resident #13 had a similar issue with a completed assessment not being transmitted. These deficiencies were identified through record reviews and staff interviews. The MDS Nurse, who was hired in April 2024, was in the process of identifying incomplete or untransmitted assessments. The Director of Nursing (DON) stated that the previous MDS staff was let go in January 2024 due to untimely completion of assessments, and a consulting company was used temporarily. However, the consultant staff also failed to complete assessments in a timely manner. The facility was aware of the backlog in MDS assessments and was working to address it, with the new MDS Nurse tasked with completing the assessments from oldest to newest.
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What surveyors actually found near you
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Signature Healthcare Of Chapel Hill | 2.1 mi | ★★★★★ | 0 | 0 |
| Parkview Health And Rehabilitation Center | 2.3 mi | ★★★★★ | 3 | 0 |
| Carol Woods | 4.2 mi | ★★★★★ | 0 | 0 |
| Southpoint Rehabilitation And Healthcare Center | 4.3 mi | ★★★★★ | 0 | 0 |
| The Forest At Duke Inc | 5.6 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.