Inspection Reports for Cadence at Wake Forest by Cogir
3218 Heritage Trade Dr, Wake Forest, NC 27587, United States, NC, 27587
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Inspection Report
Follow-Up
Deficiencies: 0
May 19, 2025
Visit Reason
Follow Up Construction Survey by Documentation to verify correction of previously cited deficiencies.
Findings
All previously cited deficiencies have been corrected based on documentation received, and no further action is required at this time.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanna Fay | Reported on the Follow Up Construction Survey |
Inspection Report
Capacity: 96
Deficiencies: 10
Apr 24, 2025
Visit Reason
This was a Construction Section Biennial Survey conducted to assess conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2012 Edition of the North Carolina Building Code, Institutional Occupancy.
Findings
Multiple deficiencies were cited including obstructions in corridors reducing egress width, damaged exterior siding, unclean ceilings, improperly stored oxygen bottles, missing towel bars in resident bathrooms, incomplete fire drill logs, fire safety system maintenance issues, unsecured plumbing fixtures, electrical hazards, and inadequate exhaust ventilation in specified areas.
Deficiencies (10)
| Description |
|---|
| Corridors were obstructed with furniture reducing width to less than six feet, impeding emergency egress. |
| Outside premises not maintained in a clean and safe condition due to missing siding allowing moisture intrusion. |
| Ceilings not kept clean and in good repair; yellow stain on ceiling and dust on exhaust fan. |
| Oxygen bottles improperly stored without restraint, posing hazard. |
| Bedrooms lacked towel bars for each resident; missing towel rings in bathrooms. |
| Fire drill logs lacked short descriptions of rehearsals in approximately 75% of records. |
| Fire safety systems not maintained; gaps in fire resistant ceilings, open junction box, and unapproved door hold-open devices observed. |
| Plumbing equipment not maintained; toilet in SCU Spa not securely mounted. |
| Electrical hazards present; smoke detector capped, tripped outlet near sink not functioning. |
| Exhaust ventilation not maintained in housekeeping closets, laundry, and common bathrooms; fans not working. |
Report Facts
Licensed beds: 96
Oxygen bottles unsecured: 5
Fire drill logs missing descriptions: 75
Inspection Report
Annual Inspection
Deficiencies: 1
Feb 15, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey and a complaint investigation survey from February 14 - 15, 2023. The complaint investigation was initiated by the Wake County Department of Social Services on February 2, 2023.
Findings
The facility failed to ensure quarterly pharmacy reviews with recommendations were completed by following up with the primary care provider (PCP) for 2 of 5 sampled residents (#2 and #3) for the past 3 quarters. The pharmacy recommendations regarding medication administration times and crushing instructions were not communicated or followed up with the PCP, potentially impacting resident care.
Complaint Details
The complaint investigation was initiated by the Wake County Department of Social Services on February 2, 2023, related to pharmacy review follow-up and medication administration issues.
Deficiencies (1)
| Description |
|---|
| Failed to ensure quarterly pharmacy reviews with recommendations were completed by following up with the primary care provider for 2 of 5 sampled residents (#2 and #3) for the past 3 quarters. |
Report Facts
Pharmacy review quarters missed: 3
Sampled residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| contracted pharmacist | Provided quarterly pharmacy reviews and recommendations; interviewed multiple times regarding medication administration and follow-up. | |
| Resident Care Director (RCD) | Received pharmacy recommendations and responsible for forwarding to PCP; interviewed regarding follow-up process and gaps. | |
| Special Care Coordinator (SCC) | Interviewed regarding facility procedures for forwarding pharmacy recommendations to PCP. | |
| Executive Director (ED) | Interviewed regarding facility expectations and processes for pharmacy recommendation follow-up. | |
| Primary Care Provider (PCP) | Interviewed regarding lack of receipt of pharmacy recommendations and expectations for follow-up. |
Inspection Report
Follow-Up
Deficiencies: 2
May 27, 2022
Visit Reason
Follow-up survey conducted to verify correction of previous deficiencies related to resident supervision and safety.
Findings
The facility failed to provide adequate supervision for a resident with dementia who exited the assisted living facility and was found approximately 24 hours later in a ravine, dehydrated and sunburned. Additionally, the facility failed to promptly notify law enforcement and the county department of social services after discovering the resident was missing, resulting in a delayed search and increased risk of harm.
Severity Breakdown
Type A1 Violation: 1
Type A2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure supervision for a resident with dementia who exited the facility and was found in a ravine approximately 24 hours later. | Type A1 Violation |
| Failure to immediately notify appropriate law enforcement and county department of social services after discovering a resident was missing. | Type A2 Violation |
Report Facts
Duration resident missing: 24
Time delay in law enforcement notification: 2.5
Ravine drop distance: 6
Ravine drop distance: 30
Water depth in ravine: 3.5
Speed limit: 45
Vehicles passing: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Service Director | Resident Service Director (RSD) | Named in relation to supervision failure and incident report. |
| Administrator | Facility Administrator | Named in relation to supervision failure and incident response. |
| Community Relations Director | Community Relations Director | Involved in locating missing resident. |
| MA | Medication Aide | Named in relation to medication administration and supervision failures. |
| PCA | Personal Care Aide | Named in relation to supervision failures. |
| Director of Culinary Experience | Director of Culinary Experience | Named in relation to meal tracking and resident checks. |
Inspection Report
Follow-Up
Census: 26
Capacity: 96
Deficiencies: 2
Mar 10, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 03/08/22 to 03/10/22 to verify correction of previous deficiencies related to housekeeping hazards and resident supervision.
Findings
The facility failed to ensure the Special Care Unit (SCU) was free of hazards accessible to residents and failed to provide adequate supervision for Resident #6, who exited the SCU through a bedroom window following an altercation with another resident. This resulted in a substantial risk of serious injury or death.
Severity Breakdown
Type A2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to ensure the Special Care Unit was free of hazards accessible to 26 residents, including unsecured staple gun and wire cutters. | — |
| The facility failed to provide adequate supervision for Resident #6 who exited the SCU through a bedroom window following an altercation with another resident, resulting in elopement and exposure to unsafe conditions. | Type A2 Violation |
Report Facts
Residents present in SCU: 26
Total licensed capacity: 96
SCU licensed capacity: 36
Resident #6 incident date: Mar 5, 2022
Distance resident eloped: 1.2
Frequency of resident checks: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Interviewed regarding supervision and incident documentation for Resident #6 |
| Special Care Coordinator | Special Care Coordinator (SCC) | Interviewed regarding hazardous items and resident elopement incident |
| Administrator | Administrator | Interviewed regarding facility policies and incident response |
| Medication Aide | Medication Aide (MA) | Interviewed regarding documentation and resident incident |
| Personal Care Aide | Personal Care Aide (PCA) | Interviewed regarding resident supervision and activities |
Inspection Report
Capacity: 96
Deficiencies: 3
Oct 25, 2019
Visit Reason
This facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2012 Edition of the North Carolina Building Code, Institutional Occupancy during the Construction Section Biennial Survey.
Findings
Deficiencies were cited including improper storage of oxygen cylinders posing safety hazards, facility not maintained in good repair with doors out of adjustment, and mechanical exhaust fans not operational in multiple specified locations.
Deficiencies (3)
| Description |
|---|
| Improperly storing oxygen cylinders that could potentially expose staff and residents to a ruptured cylinder. |
| Facility has failed to be maintained orderly and in good repair; doors out of adjustment and dragging on the floor at kitchen entry and pantry door. |
| Mechanical exhaust fans are not operational in multiple locations including men's and women's bathrooms, beauty shop, janitor closet, clean and soiled linens rooms, and laundry room. |
Report Facts
Licensed beds: 96
Inspection Report
Annual Inspection
Deficiencies: 2
Jul 24, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey and follow-up survey on July 23, 2019 through July 24, 2019.
Findings
The facility failed to maintain cleanliness and proper food labeling in the kitchen and food storage areas, with build-up of residues and unlabeled food items observed. Additionally, a medication administration error was found where an antihypertensive medication was given despite orders to hold it based on blood pressure parameters.
Deficiencies (2)
| Description |
|---|
| Kitchen and food storage areas were not clean and free of contamination, including black substance build-up, white residue, brownish substances, and unlabeled or undated food items. |
| Medications were not administered as ordered by a licensed prescribing practitioner for one resident, specifically Metoprolol was administered despite blood pressure parameters indicating it should be held. |
Report Facts
Residents sampled for medication administration: 5
Blood pressure reading: 99
Medication dosage: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director | Completed audit on medication error dated 06/28/19. |
| Kitchen Manager | Kitchen Manager | Interviewed regarding kitchen cleaning and food labeling responsibilities. |
| Administrator | Administrator | Interviewed regarding kitchen rounds and medication administration expectations. |
| MA | Medication Aide | Interviewed regarding medication administration and blood pressure parameters. |
Inspection Report
Capacity: 96
Deficiencies: 8
Aug 31, 2017
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2012 Edition of the North Carolina Building Code, Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were identified including lack of hand grips in one tub accessible to residents, unsafe outside premises due to obstruction of an exit door, unpleasant odors and damaged furnishings, failure to maintain fire safety equipment and building plumbing in safe operating condition, inadequate exhaust ventilation in several rooms, and improper utilization of the resident call system.
Deficiencies (8)
| Description |
|---|
| One tub accessible to residents did not have hand grips (SCU Spa tub). |
| Outside premises were not maintained in a safe condition; an outdoor chair obstructed an exit door at Stair 2. |
| Facility was not maintained free of unpleasant odors; strong unpleasant odor in Room C12 Bath. |
| Facility did not maintain all furnishings in good repair; towel bar ring missing in Room C5 Bath. |
| Failure to maintain fire safety equipment in safe operating condition; cross corridor doors had a 1/2" gap at the top, holes and gaps at fire resistant rated ceilings, corridor door latching mechanisms taped or disconnected, FDC sign missing on exterior. |
| Building plumbing equipment not maintained in operating condition; hot water turned off at sink in Room B6 Bath due to leak. |
| Exhaust ventilation not provided at required rate in three rooms; exhaust fans not working in SCU Laundry, SCU Janitor's Closet, and kitchen Janitor Closet. |
| Resident call system not properly utilized; staff did not respond to call button activation in bathroom of Room C12 because pager was not on staff member. |
Report Facts
Licensed capacity: 96
Bed count for Special Care Unit: 36
Gap size: 0.5
Exhaust ventilation rate: 2
Number of rooms without required exhaust ventilation: 3
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