BRITTHAVEN OF CHAPEL HILL

The information listed below provides an in-depth look into the type and quality of care offered at Britthaven of Chapel Hill. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

BRITTHAVEN OF CHAPEL HILL
1716 LEGION ROAD
CHAPEL HILL, NC 27517
(919) 942-2280

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only
Overall Rating

Percent of Beds Occupied

69%

Number of Residents and Certified Beds

  • Residents: 92
  • Certified Beds: 133

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By For Profit - Corporation
  • Offers Only Resident Counseling
  • This Facility is Part of a Chain or Franchise

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Nearby Cities:

Durham | Cary | Apex

Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Britthaven of Chapel Hill. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident ServicesResident ConditionsPercent of Service Days

Very High Rehabilitation Plus Extensive Services

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • Tracheostomy care
  • Ventilator or respirator
  • Isolation for active infectious disease while a resident
  • Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 2-101.2%
Total Percent:1.2%
 

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
ADL Index Range: 11-166.5%
ADL Index Range: 6-1024.2%
ADL Index Range: 0-517.7%
Total Percent:48.4%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-1610.5%
Total Percent:10.5%
 

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-168.1%
ADL Index Range: 6-106.5%
Total Percent:14.5%
 

Medium Rehabilitation

Rehabilitation 150 Minutes Per Week Minimum
  • Five days any combination of three rehabilitation disciplines
ADL Index Range: 11-165.2%
ADL Index Range: 6-108.9%
ADL Index Range: 0-55.6%
Total Percent:19.8%
 

Clinically Complex

  • Pneumonia, hemiplegia with ADL score >=5
  • Surgical wounds or open lesions with treatment
  • Burns
  • Chemotherapy while a resident
  • Oxygen therapy while a resident
  • IV medications or transfusions while a resident
  • Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1
ADL Index Range: 6-10
- No Signs of depression
5.6%
Total Percent:5.6%
 

Rating Details For Britthaven of Chapel Hill

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per DayReportedExpected
Registered Nurse (RN) Hours38 Minutes1 Hour and 1 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours1 Hour and 18 Minutes38 Minutes
Certified Nursing Assistant (CNA) Hours2 Hours and 59 Minutes2 Hours and 31 Minutes
Total Licensed Nurse Hours1 Hour and 56 Minutes1 Hour and 39 Minutes
Total Nurse Hours4 Hours and 55 Minutes4 Hours and 11 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for North Carolina are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This FacilityNorth Carolina Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season90-100%92%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%92%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder4%4%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair8%9%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder64%60%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse12%12%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain2%3%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores13%11%
Percent of Long-Stay Residents Who Are More Depressed or Anxious26%15%
Percent of Long-Stay Residents Who Lose Too Much Weight10%9%
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores2%4%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased17%20%
Percent of Long-Stay Residents Who Were Physically Restrained5%4%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection10%11%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season87%84%
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination88%83%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Had Moderate to Severe Pain11%17%
Percent of Short-Stay Residents Who Have Pressure Sores15%11%
Percent of Short-Stay Residents Who Have Delirium-2%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 03/11/2011.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Environmental

Have a Program to Keep Infection from Spreading.
  • Inspection Date: 09/30/2010
  • Correction Date: 10/25/2010

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 03/11/2011
  • Correction Date: 04/07/2011

Resident Assessment

Make Sure That a Doctor Approves a Resident's Admission in Writing and That Each Resident Has a Doctor.
  • Inspection Date: 09/30/2010
  • Correction Date: 10/25/2010

Enforcement

Below is a list of any civil penalities or denials of payment for new admissions (DPNA) that this facility received in the previous three years. Note: Monetary figures are not available for DPNAs.

Action TakenDateAmount
Civil Money Penalty (CMP)08/14/2009$2,015
Civil Money Penalty (CMP)08/14/2009$7,118
Civil Money Penalty (CMP)10/04/2008$7,313
Civil Money Penalty (CMP)07/27/2010$20,000
Civil Money Penalty (CMP)10/04/2008$46,150
Denial of Payment for New Admission (DPNA)10/04/2008-

Deficiencies from Complaints and Incidents

The table below lists incident reports by the nursing staff or administration for Britthaven of Chapel Hill, as well as complaints by residents or their family in the previous three years.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Formal ComplaintsDegree of HarmResidents Affected

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Complaint Filed: 10/17/2008
  • Correction Date: 12/01/2008

Mistreatment

Protect Each Resident from All Abuse, Physical Punishment, and Being Separated from Others.
  • Complaint Filed: 10/04/2008
  • Correction Date: 12/01/2008
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
  • Complaint Filed: 10/04/2008
  • Correction Date: 12/01/2008
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
  • Complaint Filed: 10/04/2008
  • Correction Date: 12/01/2008
Protect Each Resident from All Abuse, Physical Punishment, and Being Separated from Others.
  • Complaint Filed: 07/27/2010
  • Correction Date: 07/27/2010

Pharmacy Service

1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
  • Complaint Filed: 07/27/2010
  • Correction Date: 02/15/2010
Make Sure That Residents Are Safe from Serious Medication Errors.
  • Complaint Filed: 07/27/2010
  • Correction Date: 02/15/2010

Quality Care

Give Professional Services That Meet a Professional Standard of Quality.
  • Complaint Filed: 08/14/2009
  • Correction Date: 09/14/2009
Give Professional Services That Meet a Professional Standard of Quality.
  • Complaint Filed: 07/27/2010
  • Correction Date: 02/15/2010

Resident Assessment

Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
  • Complaint Filed: 10/17/2008
  • Correction Date: 12/01/2008

Resident Rights

Properly Hold, Secure and Manage Each Resident's Personal Money Which is Deposited with the Nursing Home.
  • Complaint Filed: 07/23/2008
  • Correction Date: 08/12/2008
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
  • Complaint Filed: 01/28/2010
  • Correction Date: 02/18/2010

Fire Safety

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Britthaven of Chapel Hill had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 03/31/2011.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Automatic Sprinkler Systems

An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 03/03/2010
  • Correction Date: 04/19/2010

Building Construction

Approved Construction Type or Materials.
  • Inspection Date: 03/03/2010
  • Correction Date: 04/19/2010

Building Service Equipment

Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/26/2011

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 03/03/2010
  • Correction Date: 04/19/2010
Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 10/22/2010
  • Correction Date: 11/18/2010
Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/26/2011

Electrical

Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 03/03/2010
  • Correction Date: 04/19/2010
Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/26/2011

Exits and Egress

Exits That Are Accessible at All Times.
  • Inspection Date: 03/03/2010
  • Correction Date: 04/19/2010

Fire Alarm Systems

A Fire Alarm System That Can Be Heard Throughout the Facility.
  • Inspection Date: 10/22/2010
  • Correction Date: 11/18/2010
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/26/2011

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times.
  • Inspection Date: 03/03/2010
  • Correction Date: 04/19/2010
Exits That Are Free from Obstructions and Can Be Used at All Times.
  • Inspection Date: 10/22/2010
  • Correction Date: 11/18/2010
Exits That Are Free from Obstructions and Can Be Used at All Times.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/26/2011
Restrictions on the Use of Flammable Curtains.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/26/2011

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 03/03/2010
  • Correction Date: 04/19/2010
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/26/2011

Illumination and Emergency Power

Properly Located and Lighted "Exit" Signs.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/26/2011

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas.
  • Inspection Date: 10/22/2010
  • Correction Date: 11/18/2010

Miscellaneous

Fire Safety Features Required by Current Fire Safety Codes.
  • Inspection Date: 10/22/2010
  • Correction Date: 11/18/2010

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
  • Inspection Date: 03/03/2010
  • Correction Date: 04/19/2010
Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
  • Inspection Date: 03/31/2011
  • Correction Date: 04/26/2011

Vertical Openings

Proper Stairway Enclosures and Vertical Shafts.
  • Inspection Date: 03/03/2010
  • Correction Date: 04/19/2010
Source: Medicare Nursing Home Compare; Division of Health Service Regulation-Nursing Home Licensure and Certification - Retrieved 2011