Inspection Report
Capacity: 85
Deficiencies: 3
Mar 12, 2024
Visit Reason
The visit was a Construction Section Biennial Survey to assess compliance with the 2006 North Carolina State Building Code(s) for Institutional Occupancy and the 2005 Rules for the Licensing of Adult Care Homes of Seven or More Beds.
Findings
Deficiencies were noted including incomplete drywall ceiling repair in the 1st Floor Dining Room, failure to maintain fire system safety components such as a smoke detector in room 229, and plumbing issues including the ice machine drain lacking a 2" air gap.
Deficiencies (3)
| Description |
|---|
| Ceilings were not kept in good repair; incomplete drywall ceiling repair in 1st Floor Dining Room. |
| Fire Alarm Control Panel indicated trouble with smoke detector in room 229; detector ordered but not yet installed. |
| Building's plumbing system not maintained safely; ice machine drain in kitchen lacks a 2" air gap. |
Report Facts
Licensed capacity: 85
Special Care Unit beds: 35
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 19, 2023
Visit Reason
The Adult Care Licensure Section and the Wake County Department of Social Services conducted a follow-up survey and complaint investigation initiated by the Wake County Department of Social Services on November 8, 2022, regarding allegations of abuse and resident rights violations at Sunrise of Cary.
Findings
The facility failed to ensure that 2 of 6 sampled residents (#3 and #6) were treated with respect, dignity, and consideration. Resident #6 was verbally intimidated and forced to shower under duress, and Resident #3, who had a language barrier, was forced to shower on multiple occasions after declining care. The facility also failed to report allegations of abuse to the Health Care Personnel Registry within 24 hours as required.
Complaint Details
The complaint investigation was initiated by the Wake County Department of Social Services on November 8, 2022, following a report from Resident #6's family member alleging that Resident #6 was forcibly showered after refusing care and was verbally intimidated. The family member also reported concerns about staff conduct and the facility's handling of the incident.
Severity Breakdown
Type A2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with respect, dignity, and consideration, including forcing Resident #6 to shower under duress and forcing Resident #3 to shower despite refusal. | Type A2 Violation |
| Failure to report allegations of abuse and neglect to the Health Care Personnel Registry within 24 hours for an incident involving Resident #6. | — |
Report Facts
Residents sampled: 6
Residents with rights violations: 2
Days late reporting abuse: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Personal Care Aide (PCA) | Named in abuse incident involving forcibly showering Resident #6 and failure to report abuse timely |
| Staff A | Personal Care Aide (PCA) | Assisted Staff C in forcibly showering Resident #6 |
| Staff B | Lead Personal Care Aide (PCA) | Involved in incident with Resident #6 and overheard verbal threats |
| Resident Care Director (RCD) | Documented progress notes and submitted Health Care Personnel Registry report | |
| Executive Director (ED) | Conducted investigation of abuse incident involving Resident #6 | |
| Corporate Executive Director (CED) | Oversaw facility operations and provided statements regarding abuse incident and reporting | |
| Special Care Coordinator (SCC) | Responsible for resident care coordination and reporting refusals or forced care |
Inspection Report
Annual Inspection
Census: 34
Capacity: 35
Deficiencies: 9
Oct 4, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation on September 28 and 29, 2022, desk survey on September 30, 2022, and onsite October 3 and 4, 2022.
Findings
The facility failed to ensure adequate staffing and supervision in the special care unit (SCU), resulting in multiple resident falls with injuries and delayed or missed personal care. Additionally, medication administration errors and failure to provide ordered nutritional supplements were noted. The facility also failed to submit complete accident and incident reports to the local Department of Social Services (DSS) as required.
Complaint Details
The inspection included a complaint investigation conducted on September 28 and 29, 2022.
Severity Breakdown
Type A1: 1
Type A2: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Personal care aides were assigned dietary aide duties including setting tables, pouring beverages, plating food, serving meals, clearing dishes, washing dishes, cleaning dining tables and floors, which is not permitted. | — |
| Resident #6 did not receive personal care including incontinence care and assistance to get up, dressed, and ready for breakfast on 10/04/22. | — |
| Facility failed to provide supervision for 3 residents (#4, #6, and #7) with histories of impaired mobility and multiple falls resulting in injuries and emergency evaluations. | Type A1 |
| Facility failed to ensure 10 hours between breakfast and dinner meals for 34 residents on the SCU. | — |
| Resident #7 was not provided ordered nutritional supplements three times daily. | — |
| Resident #7 was not consistently assisted with eating meals despite cognitive decline and need for varied levels of assistance. | — |
| Resident #9 was not administered Voltaren Gel 1% topical medication as ordered due to unavailability, and was administered half the ordered dose of Guaifenesin liquid for cough. | — |
| Facility failed to submit accident and incident reports to the local Department of Social Services for 3 residents (#6, #7, and #8) who required emergency medical evaluation or hospitalization. | — |
| Facility failed to ensure sufficient staff present at all times in the SCU to meet residents' needs for 6 of 23 sampled shifts, resulting in delayed or unmet supervision and personal care needs. | Type A2 |
Report Facts
Medication error rate: 7
Resident #6 falls: 9
Resident #8 falls: 18
Staff shortage: 36
Staff shortage: 165
Staff shortage: 501
Resident #7 weight loss: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Not provided | Lead PCA | Responsible for overseeing accident/incident reports and notifying family and providers. |
| Not provided | Resident Care Director | Reviewed accident/incident reports and responsible for faxing reports to DSS. |
| Not provided | Administrator | Reviewed accident/incident reports and responsible for staff scheduling oversight. |
| Not provided | Assisted Living Coordinator | Responsible for scheduling PCAs and coordinating agency staff. |
| Not provided | Medication Aide | Responsible for medication administration and reordering medications. |
| Not provided | Wellness Nurse | Responsible for ordering medications and reviewing medication administration. |
Inspection Report
Capacity: 85
Deficiencies: 10
Aug 30, 2018
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with building codes and physical plant requirements for the licensed adult care home.
Findings
Multiple deficiencies were identified related to physical plant conditions including failure to meet building code requirements at time of construction, housekeeping and furnishings not maintained in good repair, hazards such as unsecured oxygen bottles, fire safety equipment and building components not maintained in safe operating condition, hot water temperature exceeding allowed limits, and non-functioning exhaust ventilation in required areas.
Deficiencies (10)
| Description |
|---|
| Exit door to SCU from elevator lobby lacked required signage for delayed egress door. |
| Walls not kept clean and in good repair with dings, holes, and mildew stains in various rooms. |
| Furnishings not kept in good repair including damaged doors and furniture. |
| Facility not maintained free of hazards including bent fire door astragal and unsecured oxygen bottles. |
| Failure to maintain fire safety systems in safe condition due to holes/gaps in fire rated walls and ceilings. |
| Fire safety doors had gaps, were held open improperly, or did not latch automatically. |
| Fire safety equipment obstructed or not maintained in operating condition including sprinkler heads and fire alarm panel in trouble mode. |
| Electrical equipment not maintained in safe operating condition including open breaker and improper use of extension cords. |
| Hot water temperature at hair washing sink was 135°F without mixing valve, exceeding allowed maximum. |
| Exhaust ventilation not working in required areas such as Room 112 Bath. |
Report Facts
Licensed capacity: 85
Hot water temperature: 135
Oxygen bottles: 4
Inspection Report
Census: 85
Capacity: 85
Deficiencies: 6
Jul 20, 2016
Visit Reason
This report is of a Biennial Construction Survey conducted to assess compliance with the 2006 North Carolina State Building Code(s) for Institutional Occupancy and the 2005 Rules for the Licensing of Adult Care Homes of Seven or More Beds.
Findings
Multiple deficiencies were noted including improper storage of oxygen cylinders, unsafe stairwell storage, unprotected wall and ceiling penetrations compromising fire-resistance, doors that do not close or latch properly, non-functioning exit signage, and plumbing equipment issues such as a loose toilet.
Deficiencies (6)
| Description |
|---|
| Improper storage of oxygen cylinders in rooms 329 and 230, stored loose on the floor and in beverage crates that cannot prevent tipping. |
| Items stored near the Exit in Stair A, 1st Floor, creating a hazard. |
| Unprotected wall and ceiling penetrations in multiple locations including electrical closets near rooms 319, 309, 225, 103; IT Closet near room 210; phone room; corridor ceilings; Wellness Office; stairwell; kitchen; elevator pump room; theatre closet. |
| Doors in multiple locations (e.g., rooms 323, 201, 225, 207; 2nd Floor Stairwell C; Activity Room; Employee Lounge; Laundry/Hopper Room; Service Corridor; 2nd Floor cross corridor doors) do not close completely, latch, or have other issues. |
| Exit signs not working on battery backup at front door and Stair A, 1st Floor. |
| Hall bathroom near room 210 has a toilet coming loose from the floor. |
Report Facts
Residents served: 85
Special Care Unit residents: 35
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 8, 2015
Visit Reason
The inspection was conducted to investigate deficiencies related to tuberculosis testing and supervision of residents at risk for falls, triggered by concerns about compliance with health regulations.
Findings
The facility failed to ensure that 2 of 7 sampled residents were tested for tuberculosis in compliance with control measures, and failed to provide adequate supervision for 1 of 4 sampled residents at risk for falls. Multiple interviews and record reviews revealed missing documentation of required TB skin tests and inadequate supervision leading to resident falls.
Complaint Details
The visit was complaint-related, focusing on tuberculosis testing compliance and supervision of residents at risk for falls. The report documents interviews and record reviews supporting these concerns.
Severity Breakdown
Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assure 2 of 7 sampled residents were tested for tuberculosis in compliance with control measures using the 2 step TB skin test. | — |
| Failure to assure supervision for 1 of 4 sampled residents at risk for falls. | Type B Violation |
| Failure to assure residents received care and services which were adequate, appropriate, and in compliance with relevant federal and state laws and rules related to falls. | — |
Report Facts
Residents sampled for TB testing: 7
Residents sampled for supervision: 4
Resident falls: 6
Correction date: Feb 22, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sales Director | Responsible for ensuring residents had a Step 1 TB test completed prior to moving into the facility. | |
| Health Care Coordinator | Responsible for ensuring both steps of TB testing were completed on all residents. | |
| Executive Director | Interviewed regarding TB testing procedures and supervision of residents at risk for falls. | |
| Physical Therapy Supervisor | Provided information about Resident #2's need for assistance with ambulation. | |
| Personal Care Aide | Provided information about Resident #2's assistance needs and fall risk. | |
| Care Manager | Reported on Resident #2's falls and supervision. | |
| Reminiscent Care Unit Supervisor | Discussed Resident #2's falls and plans for increased supervision. | |
| Wellness Coordinator | Interviewed about supervision and fall prevention for Resident #2. |
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