Cycle 1
Health 2025-04-30 · Fire 2025-04-30
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Chapel Hill, NC
The Cedars of Chapel Hill
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
101 Green Cedar Lane, Chapel Hill, NC
(919) 259-7903
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
12
Certified beds
Average residents
9
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-04-29
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.31% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 0% · Lower 95% interval 5.63% |
| Discharge to community | 49.88% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 46.34% · Lower 95% interval 38.68% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 11.56% |
8.2%
3.4 pts better
|
Numerator 23 · Denominator 199 |
| Staff flu vaccination coverage | 40% |
42%
2 pts worse
|
Numerator 104 · Denominator 260 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
79.9%
20.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.1%
21.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-04 · Fire 2024-06-04
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-06-16 · Fire 2022-06-16
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-04-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-04-30
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-06-25
F · Potential for more than minimal harm
2024-06-04
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-06-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-06-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-06-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-06-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-06-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-06-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-23
D · Potential for more than minimal harm
2022-06-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-06-04
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-06-04
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-06-30
B · Minimal harm
2024-06-04
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-06-30
Penalties and ownership
What sits behind the stars
Ownership
Aycock, Perry
Corporate Officer · Individual
Black, Frederick
Corporate Director · Individual
Flynn, Sara
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Locklear, Gavin
Operational/Managerial Control · Individual
Mcbride, Jack
Operational/Managerial Control · Individual
Peery Mclaughlin, Margaret
Corporate Director · Individual
Sanders, Linda
Corporate Director · Individual
The Cedars Of Chapel Hill LLC
Operational/Managerial Control · Organization
Van Sant, Jerry
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Signature Healthcare of Chapel Hill
Chapel Hill, NC
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Parkview Health and Rehabilitation Center
Chapel Hill, NC
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
#3
Carol Woods
Chapel Hill, NC
5-star overall rating with 4-star inspections with 7 fire-safety deficiencies in the latest cycle
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