Inspection Reports for The East Tower at Cardinal North Hills
320 St. Albans Drive Raleigh, NC 27609, Raleigh, NC, 27609
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 5, 2025, identified deficiencies related to water temperatures in residents' bathrooms, medication aide training and competency validation, incomplete tuberculosis testing and resident registers, and medication administration errors. Earlier inspections from October 11, 2023, showed similar issues with competency validation, tuberculosis testing, resident registers, care plan signatures, therapy follow-up, and medication administration. Inspectors cited recurring themes around staff training and competency, documentation, and medication management. No complaint investigations or enforcement actions were listed in the available reports. The pattern of deficiencies appears consistent over time without clear improvement or worsening.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 6
Date: Feb 5, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual survey and a follow-up survey on February 4-5, 2025.
Findings
The facility failed to maintain water temperatures within the required range in residents' bathrooms, had medication aides without required training and competency validation, incomplete tuberculosis testing documentation for a resident, incomplete resident registers for two residents, and failed to administer medications as ordered for one resident.
Deficiencies (6)
Water temperatures in residents' bathrooms exceeded the maximum allowed temperature of 116 degrees Fahrenheit in 6 of 7 fixtures.
Documentation was missing for one medication aide who administered medications, failing to show completion of required state-approved medication aide training.
One medication aide did not have a licensed health professional evaluate and validate competency for Licensed Health Professional Support tasks.
One resident was not tested upon admission for tuberculosis disease in compliance with control measures.
Resident Registers were not completed within 72 hours of admission for two residents, missing admission dates and signatures.
Medications were not administered as ordered for one resident, including psychiatric medication Seroquel and Albuterol inhaler for shortness of breath and wheezing.
Report Facts
Residents present: 36
Water temperature readings: 6
Medication aides sampled: 3
Residents sampled: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Named in findings for missing medication aide training and competency evaluation |
| Resident Care Coordinator | Mentioned in relation to responsibility for verifying staff training and resident documentation | |
| Facilities Management Director | Mentioned in relation to water temperature monitoring and maintenance | |
| Administrator | Mentioned in relation to oversight of water temperature, staff training, and resident documentation | |
| Medication Aide | Interviewed regarding medication administration and water temperature observations |
Inspection Report
Original Licensing
Deficiencies: 6
Date: Oct 11, 2023
Visit Reason
The Adult Care Licensure Section and the Wake County Department of Social Services conducted an initial survey on 10/10/23 to 10/11/23 at The East Tower at Cardinal North Hills.
Findings
The facility was found deficient in multiple areas including failure to ensure competency validation for licensed health professional support tasks, incomplete tuberculosis testing upon admission for residents, incomplete resident registers within 72 hours of admission, care plans not signed by physicians within required timeframes, failure to ensure follow-up on speech therapy evaluation, and medication administration errors including crushing medications that should not be crushed and improper catheter care.
Deficiencies (6)
Failed to ensure staff had been competency validated for licensed health professional support tasks by return demonstration for 3 of 3 staff related to a resident who required catheter care.
Failed to ensure 2 of 3 residents sampled were tested upon admission for tuberculosis disease in compliance with control measures.
Failed to ensure a Resident Register was completed within 72 hours of admission for 3 of 3 sampled residents.
Failed to ensure care plans were completed and signed by the physician within 30 days of admission for 3 of 3 sampled residents.
Failed to ensure follow-up on a speech therapy evaluation to meet the health care needs of 1 of 3 residents sampled.
Failed to ensure medications were administered as ordered for 1 of 4 residents observed during medication pass including errors with a medication used to treat depression and a sublingual vitamin supplement, and failed to provide catheter care with proper orders for 1 of 3 residents.
Report Facts
Medication error rate: 7
Staff providing catheter care: 11
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide | Failed to complete LHPS validation for foley care since hire. |
| Staff B | Medication Aide and Personal Care Aide | Failed to complete LHPS validation for foley care since hire and cleaned catheter tubing with disinfectant wipes without instruction. |
| Staff C | No documentation of LHPS validation; not available for interview. | |
| Administrator | Responsible for ensuring LHPS validations and Resident Registers were completed; unaware of care plan physician signature requirement. | |
| Resident Care Manager (RCM) | Provided move-in dates, reported on catheter care practices, and responsible for ensuring Resident Registers and referrals. | |
| Medication Aide (MA) | Administered medications including crushing a medication that should not be crushed; instructed to use white vinegar for catheter care. | |
| Personal Care Aide (PCA) | Reported resident choking on medications and described catheter bag changing practices. | |
| Home Health RN | Not aware of facility staff using white vinegar or disinfectant wipes for catheter care; scheduled to return for catheter change. |
Viewing
Loading inspection reports...
