Inspection Reports for Heartfields at Cary
1050 Crescent Green, Cary, NC 27518, United States, NC, 27518
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Inspection Report
Follow-Up
Deficiencies: 2
May 6, 2025
Visit Reason
This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously identified deficiencies.
Findings
Deficiencies remain uncorrected including lack of current fire and building safety inspection reports and damaged ceiling tiles with bacterial growth on the 3rd floor.
Deficiencies (2)
| Description |
|---|
| Facility did not have current fire and building safety inspection reports available for review, including Fire Official's Annual Inspection, fire alarm system inspection, fire sprinkler system inspection, health department inspection, and fire drill records. |
| Building ceilings are not kept clean and in good repair; specifically, ceiling tiles on the 3rd floor are damaged and covered with bacterial growth. |
Inspection Report
Capacity: 97
Deficiencies: 3
Nov 6, 2024
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to ensure the facility meets the 1996 Rules for the Licensing of Adult Care Homes and the 1996 North Carolina State Building Code, as well as applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds.
Findings
Deficiencies were cited related to the lack of current sanitation and fire safety inspection reports, damaged ceiling tiles with bacterial growth, mechanical and plumbing systems not maintained in a safe and operable manner, and hazards such as blocked electrical panels.
Deficiencies (3)
| Description |
|---|
| Facility did not have current fire and building safety inspection reports available for review, including fire official's annual inspection, fire alarm system, fire sprinkler system, and health department inspection reports; records of fire drills were also unavailable. |
| Building ceilings not kept clean and in good repair; specifically, damaged ceiling tiles covered with bacterial growth on the 3rd floor. |
| Building and all fire safety, electrical, mechanical, and plumbing equipment not maintained in a safe and operating condition; HVAC fan inoperable reducing climate control, clothes dryer exhaust vent not attached, lavatory full of debris preventing drainage, and storage blocking electrical panels. |
Report Facts
Licensed capacity: 97
Date of inspection: Nov 6, 2024
Inspection Report
Follow-Up
Deficiencies: 2
Nov 22, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from 11/22/22 to 11/23/22 to verify correction of previous deficiencies related to medication administration and documentation.
Findings
The facility failed to administer medications as ordered for multiple residents, including errors with antidepressants, acid reflux medication, eye drops, and a triglyceride-lowering supplement. Additionally, medication administration was not documented immediately after administration for several residents, violating facility policy.
Deficiencies (2)
| Description |
|---|
| Failed to administer medications as ordered for residents #1, #4, and #6, including errors with antidepressant, acid reflux medication, lubricant eye drops, and Omega-3 Fish Oil. |
| Failed to document medication administration immediately after administration for residents #1, #6, and #7 during the morning medication pass. |
Report Facts
Medication error rate: 13
Medications administered but not documented: 10
Medications administered but not documented: 4
Medications administered but not documented: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Medication aide who administered incorrect dose of Omega-3 Fish Oil to Resident #6 and failed to document medication administration immediately | |
| Director of Resident Care | Interviewed regarding medication administration procedures and deficiencies | |
| Administrator | Interviewed regarding awareness of medication administration documentation issues | |
| Pharmacist | Provided information about medication dispensing and orders | |
| Pharmacy Technician | Provided information about medication orders and dispensing |
Inspection Report
Follow-Up
Census: 77
Capacity: 97
Deficiencies: 6
Aug 4, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigation on 08/03/22-08/04/22.
Findings
The facility was found to be short staffed on multiple shifts, failed to administer medications as ordered for several residents, prepared medications in advance improperly, administered medications late beyond allowed time frames, failed to document medication administration immediately, and failed to respond to residents' call lights in a timely manner.
Complaint Details
The visit included a complaint investigation triggered by concerns about staffing shortages, medication administration errors, and delayed response to call lights.
Severity Breakdown
Type B Violation: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure required staffing hours for the assisted living unit with census of 57-59 residents on multiple dates. | — |
| Failed to administer medications as ordered for 2 of 3 residents during medication pass, including crushing a delayed-release medication and incorrect dosage measurement. | — |
| Failed to ensure medications prepared in advance were identified and protected from contamination for 7 of 7 sampled residents. | — |
| Failed to ensure medications were administered within one hour before or after scheduled times for 8 residents, resulting in late medication administration up to nearly 4 hours. | Type B Violation |
| Failed to document medication administration immediately following administration and observation for 8 residents during morning medication pass. | — |
| Failed to respond to residents' call lights in a timely manner, with documented delays over one hour and up to ten hours. | — |
Report Facts
Staffing shortage hours: 7
Staffing shortage hours: 7.5
Staffing shortage hours: 4.63
Medication error rate: 8
Residents observed: 8
Medication administration delay: 238
Medication administration delay: 206
Medication administration delay: 161
Medication administration delay: 168
Medication administration delay: 98
Medication administration delay: 71
Medication administration delay: 71
Medication administration delay: 71
Call light response delay: 100
Call light response delay: 646
Call light response delay: 377
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Secretary | Responsible for scheduling staff and observed medication aide preparing medications in advance and documenting late. | |
| Director of Resident Care | DRC | Aware of staffing shortages, worked on floor as PCA, and responsible for medication administration oversight. |
| Executive Director | ED | Unaware of call light response delays and medication administration delays, responsible for facility oversight. |
| Medication Aide | MA | Observed administering medications late, preparing medications in advance, and documenting medication administration late. |
Inspection Report
Annual Inspection
Capacity: 97
Deficiencies: 2
May 11, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on May 11-12, 2022 to assess compliance with medication administration and infection prevention and control requirements.
Findings
The facility failed to administer medications as ordered for multiple residents, including errors with inhalers, missed doses due to unavailable medications, and incorrect dosages. Additionally, the facility did not implement CDC and NC DHHS COVID-19 infection prevention guidance, failing to screen staff and visitors and allowing staff and visitors to be unmasked, placing residents at risk of infection.
Severity Breakdown
Type B Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to administer medications as ordered for 3 of 6 residents observed during medication passes and 1 of 5 residents reviewed, including errors with asthma inhalers, constipation medication, depression medication, and unavailable medications for pain, infection, sleep, anxiety, and agitation. | — |
| Failed to implement CDC and NC DHHS COVID-19 infection prevention guidance related to screening of staff and visitors and staff not wearing face masks while on duty. | Type B Violation |
Report Facts
Medication error rate: 14
Facility capacity: 97
Special care unit beds: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #6 | Resident | Involved in medication administration error with inhalers. |
| Resident #7 | Resident | Did not receive ordered Miralax due to medication unavailability. |
| Resident #8 | Resident | Received incorrect dosage of Zoloft medication. |
| Resident #4 | Resident | Medications for pain, infection, sleep, anxiety, and agitation were not administered due to unavailability. |
| Director of Resident Care | Director of Resident Care | Interviewed regarding medication administration policies and infection control practices. |
| Medication Aide | Medication Aide | Involved in medication administration errors and omissions. |
| SCU Director | Special Care Unit Director | Observed not wearing mask while assisting residents. |
| Interim Administrator | Interim Administrator | Reported mask use was optional per corporate guidance and screening was stopped. |
Inspection Report
Capacity: 97
Deficiencies: 14
Oct 24, 2019
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with building codes and physical plant requirements for the facility licensed for 97 residents, including a 16-bed Special Care unit.
Findings
Multiple deficiencies were cited related to building code compliance, physical plant maintenance, housekeeping, fire safety equipment, and ventilation. Issues included non-functioning emergency exit switches, corridor obstructions, poor housekeeping, unsecured oxygen bottles, fire safety door malfunctions, missing sprinkler escutcheon rings, non-operational emergency lighting, prohibited portable heaters, and inadequate exhaust ventilation.
Deficiencies (14)
| Description |
|---|
| Facility does not meet building code requirements; emergency exit switch in elevator lobby did not release exit doors and screamer box did not sound. |
| Corridors were obstructed by a garden bench narrowing egress path to less than 6 feet. |
| Ceilings not kept clean and in good repair; dust accumulation on exhaust fans; damp spot with mildew on ceiling tile; discolored and flaking ceiling finish. |
| Walls and furnishings not kept clean and in good repair; missing door knob, bathroom door not latching, dirty kitchen doors, broken door handle. |
| Facility not maintained free of offensive odors; strong urine odor in Room 124. |
| Oxygen bottles stored without means of restraint in multiple rooms, presenting hazard. |
| Failure to maintain fire safety equipment; fire doors did not close and latch properly due to magnetic hold open devices and door dragging. |
| Holes or gaps in fire resistant rated ceilings or walls allowing potential spread of fire and smoke. |
| Electrical emergency/safety lighting not maintained; emergency lights failed battery test. |
| Failure to maintain 18" clearance below sprinkler heads; items stored to ceiling obstructing sprinkler system. |
| Smoke detector not secure to ceiling. |
| Unapproved device (wood blocking) used to keep door open, impeding fire safety. |
| Unvented portable electric heaters found in building, which are prohibited. |
| Facility did not maintain required exhaust ventilation in specified spaces; multiple exhaust fans not working or insufficient. |
Report Facts
Licensed capacity: 97
Oxygen bottles without restraint: 36
Portable electric heaters: 2
Inspection Report
Follow-Up
Census: 22
Deficiencies: 2
Oct 18, 2019
Visit Reason
The Adult Care Section conducted a follow-up survey from 10/17/2019 to 10/18/2019 to verify correction of previous deficiencies related to resident rights and medication administration.
Findings
The facility failed to ensure residents received a reasonable response time from staff when they pulled their call light, with observations showing no staff response for extended periods. Additionally, medication administration errors were found for one resident involving insulin dosing inaccuracies according to the prescribed sliding scale.
Deficiencies (2)
| Description |
|---|
| Failed to ensure residents received a reasonable response time from staff when they pulled their call light. |
| Failed to ensure medications were administered as ordered for 1 of 5 sampled residents, including errors with insulin dosing. |
Report Facts
Residents on third floor: 22
Insulin administration errors: 12
Call bell response time: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Interviewed regarding staff expectations and call bell response |
| Executive Director | Executive Director (ED) | Interviewed regarding call bell system and medication administration oversight |
| Medication Aide | Medication Aide (MA) | Interviewed about insulin administration practices and errors |
| Director of Resident Care | Director of Resident Care/Licensed Practical Nurse (DRC/LPN) | Responsible for reviewing MARs and notified of insulin administration issues |
| Regional Nurse | Regional Nurse | Interviewed about medication administration record reviews and audits |
Inspection Report
Follow-Up
Deficiencies: 5
May 8, 2019
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and a complaint investigation on May 8, 9 and 10, 2019 with exit via telephone on May 13, 2019.
Findings
The facility failed to notify the physician for 1 of 5 sampled residents related to an unwitnessed fall resulting in a left hip fracture and uncontrolled pain for 3 days. Additionally, the facility failed to ensure timely staff response to call lights, missed medication doses for 2 residents, and improper infection control during medication administration.
Complaint Details
The visit included a complaint investigation triggered by concerns about failure to notify physician after a resident fall and other care issues.
Severity Breakdown
Type A1 Unabated Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify physician for 3 days after an unwitnessed fall resulting in left hip fracture and uncontrolled pain for Resident #1. | Type A1 Unabated Violation |
| Failed to ensure residents received reasonable response time from staff when call lights were pulled. | — |
| Failed to administer medications as ordered for 2 residents with missed doses of depression medication and medications for constipation and mucus thinning. | — |
| Failed to assure medications were administered in accordance with infection control measures; medication aides did not use appropriate hand hygiene techniques. | — |
| Failed to assure every resident had the right to receive care and services which are adequate, appropriate, and in compliance with rules and regulations related to health care. | — |
Report Facts
Deficiencies cited: 5
Missed medication doses: 14
Residents on floor during call light observation: 26
Medication doses missed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Medication Aide | Observed not using hand sanitizer between every resident, wore gloves during nasal spray administration |
| Staff B | Medication Aide | Observed not using hand sanitizer between residents during medication administration |
| Resident Care Coordinator | Interviewed regarding medication administration and order tracking | |
| Physician | Primary Care Physician | Interviewed regarding Resident #1 fall and Resident #5 medication dosage change |
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 11
Jan 22, 2019
Visit Reason
Annual and follow-up survey conducted to assess compliance with adult care licensure regulations and health service requirements.
Findings
The facility was found deficient in multiple areas including improper assignment of dietary duties to personal care aides, failure to complete tuberculosis testing, inadequate health care referral and follow-up, medication administration errors, failure to provide timely feeding assistance, inadequate cleaning of kitchen and dining areas, failure to serve snacks consistently, and incomplete resident profiles and care plans.
Severity Breakdown
Type A1 Violation: 1
Type B Violation: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Personal care aides in the special care unit were assigned dietary aide duties including table setting, preparing beverages and meal plates, clearing tables, and cleaning the dining room, which is not allowed. | — |
| Failure to assure 1 of 5 sampled residents was tested upon admission for tuberculosis with a two-step skin test as required. | — |
| Failure to assure health care referral and follow-up for 4 of 5 sampled residents including missed specialist visits, failure to notify PCPs of important health issues, and failure to address use of a reverse wedge pillow as a possible restraint. | Type A1 Violation |
| Failure to assure documentation and implementation of physician orders for weekly weights, weekly blood pressures, and compression stockings for sampled residents. | — |
| Failure to serve snacks three times daily consistently to residents on the assisted living unit. | — |
| Failure to serve nectar thickened milk and water as ordered to a resident requiring thickened liquids. | — |
| Failure to serve nectar thickened beverages including water, tea, milk and juice as ordered to a resident requiring thickened liquids. | — |
| Failure to provide timely feeding assistance to a resident requiring extensive assistance, resulting in delays of 25 minutes to over one hour for meal assistance. | — |
| Failure to administer medications as ordered and in accordance with facility policies for 5 of 6 residents including crushing enteric coated aspirin, missed doses of laxatives, administering medication at wrong times, and failure to clarify incomplete orders. | Type B Violation |
| Failure to complete quarterly special care unit resident profile assessments for 2 of 2 sampled residents. | — |
| Failure to assure residents received care and services which were adequate, appropriate, and in compliance with relevant laws and regulations related to health care and medication administration. | — |
Report Facts
Medication error rate: 25
Residents needing assistance with eating: 5
Residents eating dinner in SCU dining room: 12
Residents eating dinner in SCU dining room: 13
Snack cups on cart: 42
Snack cups on cart: 13
Weight loss: 33
Missed medication doses: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Director | Discussed dietary aide duties and feeding assistance delays | |
| Director of Resident Care | Responsible for medication order processing and care plans; interviewed about multiple deficiencies | |
| Executive Director | Interviewed about meal times, staffing, and overall facility compliance | |
| Wellness Coordinator | Interviewed about resident care and staff responsibilities | |
| Medication Aide | Observed and interviewed regarding medication administration errors and feeding assistance | |
| Personal Care Aide | Observed and interviewed regarding feeding assistance and cleaning duties | |
| Executive Chef | Interviewed about meal preparation and snack delivery | |
| Regional Nurse | Interviewed about LHPS reviews and compliance |
Inspection Report
Capacity: 97
Deficiencies: 3
Aug 31, 2017
Visit Reason
The visit was a Construction Section Biennial Survey to ensure the facility meets the 1996 Rules for Licensing of Domiciliary Homes, the 1996 North Carolina State Building Code, and applicable portions of the 2005 Rules for Adult Care Home of Seven or More Beds.
Findings
The facility was found to have multiple deficiencies including missing vinyl ceiling panels at the rear Lower Level Covered Courtyard Porch, improper storage of oxygen cylinders in Room 9, and damaged ceiling construction at the Lower Level Stair Tower on the Crescent Side.
Deficiencies (3)
| Description |
|---|
| Missing vinyl ceiling panels at the rear Lower Level Covered Courtyard Porch. |
| Improper storage of oxygen cylinders in Room 9, not secured to the structure or stored in approved racks. |
| Damaged ceiling construction at the Lower Level Stair Tower on the Crescent Side. |
Report Facts
Licensed capacity: 97
Inspection Report
Annual Inspection
Deficiencies: 4
Jun 1, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey on June 1-2, 2016 to assess compliance with regulations related to building maintenance, fire safety, and nutrition and food service in the adult care home.
Findings
The facility failed to maintain the reach-in cooler and stove with double oven doors in safe and working condition, with broken gaskets and oven doors. Additionally, the kitchen, dining, and food storage areas were found to be unclean, with numerous stains, residue build-up, rust, and food particles on walls, floors, equipment, and storage areas. Cleaning schedules were not properly followed or documented, and needed repairs were not timely reported or addressed.
Deficiencies (4)
| Description |
|---|
| Reach-in cooler door gasket was broken and unable to seal properly; stove oven door broken and could not close. |
| Kitchen, dining, and food storage areas were not clean or orderly, with brown stains, sticky spots, rust stains, residue build-up, and food particles on walls, floors, equipment, and storage areas. |
| Cleaning schedules were not followed or documented; last cleaning documented was March 21, 2016 despite inspections in June. |
| Needed repairs such as hole in wall, missing floor laminate, and chipped paint were not timely reported or repaired. |
Report Facts
Temperature: 45
Broken oven door opening: 4
Hole size: 4
Hole size: 2
Floor mat stain coverage: 75
Cleaning schedule last documented date: Mar 21, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding awareness of broken gasket and stove oven door, cleaning responsibilities, and cleaning schedule adherence. | |
| Maintenance Director | Interviewed regarding repairs to reach-in cooler gasket, stove oven door, and other maintenance issues. | |
| Administrator | Interviewed regarding knowledge of needed repairs and cleanliness issues. | |
| Regional Director of Health Services | Interviewed regarding oversight of dietary manager and maintenance follow-up. | |
| Cook | Interviewed regarding cleaning duties and awareness of kitchen conditions. | |
| Dietary Aide | Interviewed regarding cleaning duties, cleaning schedule, and reporting of repairs. |
Inspection Report
Capacity: 97
Deficiencies: 24
Nov 4, 2015
Visit Reason
This is a Biennial Construction Survey conducted to assess compliance with the 1996 Rules for the Licensing of Domiciliary Homes, the 1996 North Carolina State Building Code, and the 2005 Rules for Adult Care Home of Seven or More Beds.
Findings
The facility was found to have multiple deficiencies including failure to maintain buildings in good repair and clean condition, hazards related to unsecured oxygen containers and obstructed exit corridors, inadequate maintenance of emergency exits and fire resistance of building components, plumbing and safety system deficiencies, and blocked electrical panels.
Deficiencies (24)
| Description |
|---|
| Broken ceramic tiles with sharp edges around inoperative water controls in the 3rd Floor Spa. |
| Water damage to the ceiling in the Chapel. |
| Ceiling in the Dining Room patched but no finish coat applied. |
| Rotten, warped, and loose side-splash at the sink in the Staff breakroom. |
| Stained floors and walls in the Staff Toilet on the Terrace Level needing repair/paint. |
| Scratched and scarred corner bead and door frames in Resident Room 3 in the SCU. |
| Unsupported oxygen bottles stored in Room 112, creating hazard. |
| EXIT corridor in the Terrace Level narrowed to less than 4 feet due to stored boxes and furniture. |
| EXIT doors with 15-second delay not labeled with required delayed egress signage. |
| Faded delayed egress signage on EXIT door leading out of stairwell beside service corridor. |
| Damaged rated wall around stair tower in Boiler Room with holes exposing studs. |
| Transfer grille without damper cut into corridor door of Janitor's Closet on 3rd floor. |
| Holes cut into corridor/elevator shaft wall above ceiling across from Room 307 and plumbing shaft wall outside Room 318. |
| Multiple cable penetrations above ceiling on 2nd Floor including Rooms 225, 228, and Wellness Office. |
| Large hole above ceiling in 1st floor kitchen above entrance to Dining Room. |
| Several 3-inch holes above ceiling above EXIT door to South Tower. |
| Conduits penetrating wall with unprotected gaps above ceiling and sinks in Main Kitchen. |
| Door to Resident Storage held open by wire preventing closing and latching. |
| Door from main corridor to Laundry area missing latch plate and closer. |
| Soiled Linen closet in SCU broken and will not close and latch. |
| Condensate pipe for ice machine in Main Kitchen resting on top of floor drain, lacking air gap. |
| No vacuum breaker for hand-held wand at tub in 3rd Floor Spa. |
| Broken bracket on emergency light near rooftop air conditioning units with light hanging by wires. |
| Electrical panel in 2nd Floor Storage Room blocked by miscellaneous items. |
Report Facts
Licensed capacity: 97
Delay time: 15
Hole dimensions: 18
Hole dimensions: 24
Hole dimensions: 18
Hole dimensions: 12
Hole diameter: 3
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