Inspection Reports for Sunrise of Raleigh

NC, 27612

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Inspection Report Annual Inspection Deficiencies: 3 Mar 11, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 03/11/25 - 03/12/25 to assess compliance with adult care home regulations.
Findings
The facility was found to have unsecured oxygen cylinders posing a hazard, medication administration errors for two residents including missed topical medication and incorrect timing of medication administration, and inaccurate medication administration records related to Lidocaine patches.
Deficiencies (3)
Description
Unsecured oxygen cylinders stored in a resident's room, posing a safety hazard.
Medications were not administered as ordered for 2 of 6 residents, including failure to administer a topical antibiotic ointment and incorrect timing of acid reflux medication.
Medication administration records were inaccurate for a resident related to Lidocaine patch application and removal documentation.
Report Facts
Medication error rate: 10 Medication errors: 3 Medication administration opportunities: 30
Employees Mentioned
NameTitleContext
Medication Aide Mentioned in relation to medication administration errors and failure to notify Resident Care Coordinator about missing medications.
Resident Care Coordinator (RCC), Registered Nurse Responsible for processing medication orders, ordering medications, and clarifying medication administration instructions.
Lead Personal Care Aide (PCA) Interviewed regarding oxygen cylinder storage practices.
Administrator Interviewed regarding facility policies on oxygen cylinder storage and medication administration.
Pharmacist Interviewed regarding medication orders and administration instructions.
Inspection Report Capacity: 100 Deficiencies: 9 Sep 7, 2023
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant and safety including failure to meet licensure and code requirements for electromagnetic locks and delayed egress doors, housekeeping and furnishings not kept clean and in good repair, hazards such as improperly stored oxygen bottles and trip hazards, failure to maintain electrical emergency lighting and fire safety equipment in safe operating condition, failure to maintain fire safety components and plumbing piping safely, and inadequate exhaust ventilation in specified spaces.
Deficiencies (9)
Description
Electromagnetic locks lack a central emergency release switch on the Terrace Level SCU and delayed egress doors on the Third floor SCU did not release upon fire alarm activation.
Walls, ceilings, and floors are not kept clean and in good repair, including damaged ceiling tiles, flood damage, heavy damage from a car, and disrepair in laundry ceiling and stairway carpet.
Facility not maintained free from hazards; oxygen bottles improperly stored without restraint and a floor outlet cover plate creates a trip hazard.
Electrical emergency/safety lighting equipment not maintained in safe operating condition; multiple emergency lights failed to illuminate on test.
Failure to maintain fire safety systems; holes or gaps in fire resistant rated ceilings or walls, sprinkler heads obstructed by wasp nest and dust, and doors not closing or latching properly.
Electrical equipment not maintained in safe and operating condition; recessed can light out and unsecured.
Unapproved device (furniture) used to keep a door open, impeding quick door closure during fire alarm.
Failure to maintain exhaust ventilation in specified spaces; exhaust fans not venting properly or not working.
Failure to maintain plumbing piping with minimum 2" air gap; ice machine drain line sitting directly on floor drain.
Report Facts
Licensed beds: 100 Special Care Unit beds: 46 Oxygen bottles improperly stored: 3 Emergency lights not illuminating: 14 Hole size: 12 Hole size: 0.5 Cover plate size: 24
Inspection Report Follow-Up Deficiencies: 3 Jan 25, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 01/25/23 - 01/26/23 to verify correction of previous deficiencies related to medication staff qualifications and medication administration.
Findings
The facility failed to ensure medication aides completed required training and failed to administer medications as ordered for multiple residents, resulting in medication errors including administering incorrect dosages, expired insulin, and inaccurate medication administration records. These deficiencies posed risks to resident health and safety.
Severity Breakdown
Type B Violation: 1
Deficiencies (3)
DescriptionSeverity
Failed to ensure 2 of 5 sampled medication aides completed required 5, 10, or 15 hour training.
Failed to administer medications as ordered for 3 residents, including errors with nerve pain medication, skin protectant ointment, supplements, and expired insulin. Type B Violation
Medication administration records were inaccurate for 1 resident, including documentation of a one-time dose medication not administered and duplicate supplement entries.
Report Facts
Medication error rate: 24 Medication error rate: 15 Medication doses: 17 Insulin expiration days: 28 Medication administration dates: 28
Employees Mentioned
NameTitleContext
Staff B Medication Aide Failed to complete required medication staff training
Staff C Medication Aide Failed to complete required medication staff training
Business Office Manager Interviewed regarding personnel record reviews and medication aide training documentation
Administrator Interviewed regarding responsibility for auditing personnel records and medication aide training
Medication Aide Administered incorrect medications and doses, including Vitamin D3, Vitamin C, Flaxseed Oil instead of Omega-3, and failed to administer Fluconazole
Senior Resident Care Director Interviewed regarding medication administration procedures and discrepancies
Wellness Nurse Interviewed regarding medication order entry and medication administration record accuracy
Regional Nurse Interviewed regarding medication aide training and medication expiration procedures
Inspection Report Follow-Up Deficiencies: 3 Oct 13, 2022
Visit Reason
The Adult Care Licensure Section and the Wake County Department Social Services conducted a follow-up survey and a complaint investigation initiated by the Wake County Department of Social Services on 10/10/22.
Findings
The facility failed to administer medications as ordered for one resident related to depression and anxiety medications, failed to ensure infection control measures during medication administration, and failed to ensure timely referral and follow-up for acute health care needs for one resident, resulting in serious physical harm.
Complaint Details
Complaint investigation initiated by the Wake County Department of Social Services on 10/10/22, including follow-up survey on 10/13/22 and 10/14/22.
Severity Breakdown
Type A1 Violation: 1
Deficiencies (3)
DescriptionSeverity
Failed to administer medications as ordered for Resident #4 related to medications used to treat depression and anxiety, including failure to implement medication changes.
Failed to ensure medications were administered in accordance with infection control measures to prevent disease transmission and cross-contamination during medication pass.
Failed to ensure referral and follow-up to meet acute health care needs for Resident #1 by delayed response to reported severe hip pain related to a right hip fracture. Type A1 Violation
Report Facts
Deficiencies cited: 3 Correction date: Nov 13, 2022
Inspection Report Capacity: 100 Deficiencies: 11 Dec 5, 2019
Visit Reason
This facility was surveyed for conformance with applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 Edition of the North Carolina Building Code(s), Institutional Occupancy, as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were cited related to physical plant and safety including lack of an emergency power switch for electromagnetically locked doors, damaged ceiling construction due to water migration, unsecured ceiling access panel, interior doors not latching properly, improperly stored oxygen cylinders, fire safety and building maintenance issues such as unprotected water lines penetrating fire rated walls, malfunctioning corridor doors, storage interfering with sprinkler coverage, non-illuminating emergency light, and failure to install mechanical exhaust in the residential laundry room.
Deficiencies (11)
Description
No on/off emergency switch capable of interrupting power to all electromagnetically locked doors was identified on the Terrace Level/SCU.
Ceiling construction damaged due to water migration outside Room T-10, Care Manager's Office, and Terrace Roof outside Room T-3.
Ceiling access panel outside Stairway 2/Level 1 in the hall was not secured.
Interior doors at multiple locations (Terrace Front Door, Main Laundry Room Entry, Kitchen Storage Room, Kitchen Service Door, Room 318) do not latch due to loose hinges.
Oxygen bottles not secured in storage racks in Rooms T-2, T-5, and 207.
Water lines penetrating a one-hour fire rated wall assembly in the Riser Room are not fire protected.
Portions of wall construction missing above the Riser Room entry door through the one-hour fire rated wall assembly.
Magnetically held open corridor doors in the Parlor and at the top of the monumental stair released upon fire alarm activation but did not close due to latching hardware failure.
Dry food boxes stored less than 18 inches from the ceiling in the Main Kitchen Pantry interfere with sprinkler head coverage.
Emergency light unit did not illuminate when tested at the Terrace Level/SCU.
Mechanical exhaust system not installed in the Residential Laundry Room adjacent to Room 320.
Report Facts
Licensed beds: 100 Special Care Unit beds: 46
Inspection Report Original Licensing Capacity: 100 Deficiencies: 6 Oct 11, 2017
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
The survey identified multiple deficiencies including improper storage of oxygen bottles, failure to maintain emergency fire alarm systems and fire safety equipment in safe operating condition, gaps in fire resistant rated ceilings, inadequate emergency lighting and exit signage, and failure to maintain exhaust ventilation equipment.
Deficiencies (6)
Description
Oxygen bottles were improperly stored without means of restraint, presenting a hazard to occupants.
Failure to maintain the facility's emergency fire alarm system devices and equipment in a safe operating condition; audible function of fire alarm devices did not work and duct detector sampling tube was clogged.
Failure to maintain the building's fire safety systems in a safe condition; holes or gaps at penetrations through fire resistant rated ceilings and missing escutcheon on fire sprinkler head.
Items stored within 18 inches of fire sprinkler head, use of non-fire resistant rated insulation material allowing fire and smoke to spread.
Electrical emergency/safety lighting equipment not maintained in safe operating condition; emergency light and exit sign deficiencies noted.
Failure to maintain exhaust ventilation equipment; laundry exhaust fan and central exhaust system in Special Care Unit not working.
Report Facts
Licensed beds: 100
Inspection Report Annual Inspection Deficiencies: 2 Jun 30, 2016
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility from June 28, 2016 to June 30, 2016.
Findings
The survey identified deficiencies including hazardous and poorly maintained refrigerators in 10 of 14 sampled resident rooms in the Memory Care unit, with sharp metal edges and thick frost buildup posing safety risks. Additionally, the facility failed to ensure tuberculosis (TB) disease testing compliance for one of five sampled residents, specifically missing the TB skin test read date.
Deficiencies (2)
Description
Facility failed to maintain 10 of 14 sampled resident rooms' refrigerators in a clean, orderly, and hazard-free manner, with issues such as missing refrigerator handles, sharp metal edges projecting from screw holes, thick frost buildup, rust, and food particles.
Facility failed to assure tuberculosis disease testing upon admission for 1 of 5 sampled residents, with Resident #4's TB skin test not read as required.
Report Facts
Number of sampled resident rooms with refrigerator hazards: 10 Number of sampled residents with TB testing deficiency: 1 Dates of annual survey: June 28, 2016 to June 30, 2016
Employees Mentioned
NameTitleContext
Executive Director Executive Director Interviewed regarding refrigerator conditions and replacement plans
Care Manager Care Manager Interviewed regarding awareness of refrigerator hazards
Maintenance Coordinator Maintenance Coordinator Interviewed and observed applying compound to cover sharp edges on refrigerators
Wellness Nurse Wellness Nurse Interviewed regarding TB skin test administration and monitoring
Resident Care Director Resident Care Director Interviewed regarding responsibility for TB skin test compliance
Administrator Administrator Interviewed regarding awareness of TB testing deficiencies
Inspection Report Follow-Up Deficiencies: 2 Feb 10, 2016
Visit Reason
This is a biennial follow-up survey conducted to verify correction of previously cited deficiencies at the facility.
Findings
Most previously cited deficiencies have been corrected; however, some deficiencies remain uncorrected, including failure to keep walls, ceilings, and floors clean and in good repair, and failure to maintain fire safety systems due to gaps and openings in fire resistant rated ceilings.
Deficiencies (2)
Description
Facility failed to keep walls, ceilings, and floors clean and in good repair, including a floor requiring cleaning in front of the freezer in the 1st Floor Sunroom Bistro.
Failure to maintain fire safety systems in a safe manner due to gaps and open penetrations in fire resistant rated ceilings, including a hole in the fire resistant rated stairwell wall on the Terrace Floor Staff Break Room side.
Inspection Report Biennial Survey Capacity: 100 Deficiencies: 12 Dec 8, 2015
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 Edition of the North Carolina Building Code(s), Institutional Occupancy and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
The survey identified multiple deficiencies including lack of current sanitation inspection reports, failure to maintain walls, ceilings, floors, and furnishings in good repair, unsafe storage of oxygen bottles, obstruction of electrical panels, damaged exterior building components, and multiple fire safety system failures including non-operational fire alarm devices, blocked fire doors, and obstructed emergency exit pathways.
Deficiencies (12)
Description
Facility failed to have current (within the calendar year) kitchen and building sanitation inspection reports available for review.
Facility failed to keep walls, ceilings, and floors clean and in good repair, including damaged drywall, peeling paint, frayed carpet, and holes in walls.
Facility failed to keep furnishings in good repair, including detached cabinet door hanging by one hinge.
Storage of oxygen bottles was not maintained to prevent falling or being knocked over, presenting a hazard.
Access to electrical panels was obstructed by stored items, violating building code clearance requirements.
Exterior building maintenance issues including damaged soffit of patio ceiling and damaged entrance canopy.
Failure to maintain emergency fire alarm system devices and equipment in safe operating condition, including non-operational fire alarm audio visual device and clogged smoke detector sampling tube.
Fire safety components not maintained safely; doors blocked open by unapproved devices or wedged open, preventing proper smoke and fire containment.
Failure of fire safety doors to completely close and latch, including broken door coordinators and latches on multiple doors.
Fire resistant rated ceilings and walls had gaps and holes allowing potential spread of fire and smoke.
Failure to maintain electrical emergency/safety related equipment in safe operating condition; emergency lights and exit signs did not operate when tested.
Emergency exit pathways obstructed by stored items in stairway landings, delaying potential evacuation.
Report Facts
Licensed bed capacity: 100
Inspection Report Annual Inspection Deficiencies: 3 Dec 19, 2014
Visit Reason
The Adult Care Licensure Section and the Wake County Human Services conducted an annual survey and complaint investigation on December 16-19, 2014.
Findings
The facility failed to assure that only qualified staff administered medications, specifically a medication error where a personal care manager (PCM) mistakenly fed a topical antifungal cream orally to a resident. The facility also failed to notify the Health Care Personnel Registry regarding treatment cream administration by unqualified staff.
Complaint Details
The visit included a complaint investigation triggered by an incident on 10/8/14 where a personal care manager mistakenly fed a topical antifungal cream orally to Resident #1. Poison Control was contacted and the resident was monitored with no apparent injury. The complaint was substantiated by interviews and record review.
Severity Breakdown
Type A2 Violation: 1
Deficiencies (3)
DescriptionSeverity
Facility failed to assure that only qualified staff administered medications, resulting in a personal care manager feeding a topical antifungal cream orally to a resident. Type A2 Violation
Facility failed to notify the Health Care Personnel Registry regarding treatment cream administration by unqualified staff.
Facility failed to assure every resident had the right to receive care and services which are adequate, appropriate, and in compliance with relevant laws related to medication administration.
Report Facts
Sampled residents: 7 Incident date: Oct 8, 2014 Cream administration times: 2 Medication aide assignment: 1 PCM hire date: Sep 3, 2014
Employees Mentioned
NameTitleContext
Personal Care Manager (PCM) Nurse Aide / Care Manager Administered topical cream orally to resident; lacked medication administration clinical skills validation
Medication Aide (MA) Gave topical cream to PCM without instruction; responsible for medication administration
Lead Care Manager (LCM) #1 Lead Care Manager Reported medication error and interviewed regarding medication administration policies
Lead Care Manager (LCM) #2 Lead Care Manager Provided information on medication administration policies and resident care
Interim Administrator/Reminiscence Coordinator/Executive Director (ADM) Administrator/Executive Director Managed incident response, contacted Poison Control, and implemented corrective actions
Resident #1's Primary Care Physician (PCP) Primary Care Physician Aware of medication error incident and confirmed no harm to resident

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