Cadence at Wake Forest

The facility failed to ensure that quarterly pharmacy review recommendations were followed up with primary care providers for two residents over three consecutive quarters. Specifically, recommendations to change the administration time of Rosuvastatin from morning to evening were not communicated to the physician, leaving residents at risk for ineffective treatment.

The facility failed to ensure that quarterly pharmacy reviews with recommendations were properly followed up with the primary care provider. Specifically, for 2 of 5 sampled residents, the facility did not document necessary actions or physician notifications regarding pharmacy review findings for the past three quarters.

The facility failed to ensure adequate supervision for a resident who exited the facility and was found in a ravine 24 hours later. Although the resident's care plan noted a history of wandering and required frequent checks, there was no signed waiver on file to excuse night shift checks, and the resident's needs were not met.

The facility failed to provide adequate supervision for a resident with dementia and a history of wandering, resulting in the resident exiting the building and being found in a ravine 24 hours later. Although the resident's care plan required close monitoring due to previous elopement, the facility failed to implement necessary safeguards or maintain required documentation for unsupervised night checks.

The facility failed to ensure the Special Care Unit (SCU) was free of hazards by leaving a staple gun and wire cutters accessible to residents in an unsecured tote box. The box was left in an open, unmonitored common activity room without staff presence. This created a safety risk for residents, particularly those prone to wandering and rummaging through containers.

The facility failed to ensure the Special Care Unit (SCU) was free of hazards. A staple gun and wire cutters were found unsecured in an accessible tote box in a common activity room.

The facility failed to ensure adequate supervision for residents. One of six sampled residents exited the special care unit through a bedroom window following an altercation with another resident.

The facility failed to ensure the Special Care Unit (SCU) was free of hazards by leaving a paring knife in an unlocked drawer in the kitchen. Additionally, the kitchen and dining room were accessible to residents without staff supervision, posing a risk to residents with dementia and wandering behaviors.

The facility failed to maintain required aide duty hours to meet the needs of the residents. The plan of correction indicates a need for improved monitoring of staffing needs and notification processes to ensure compliance with mandated shift coverage.

The facility failed to maintain the Special Care Unit (SCU) in a safe and orderly manner by leaving a paring knife in an unlocked drawer in the dining room kitchen. The kitchen and dining room areas were accessible to residents without staff supervision, creating a potential hazard.