Heartfields at Cary

The facility failed to ensure a resident received adequate and appropriate care, resulting in a fractured right shoulder and extensive bruising across the left arm, hip, chest, and flank. Evidence indicates the resident required increased assistance for transfers and ADLs, yet sustained significant injuries while under the facility's care.

The facility failed to ensure a resident received adequate and appropriate care and services. Specifically, a resident with a fractured shoulder and multiple bruises was not provided care consistent with their care plan, which required physical assistance for transfers and ambulation with standby supervision.

The facility failed to administer medications as ordered for several residents, resulting in a 13% medication error rate. Specifically, a resident was administered only one capsule of Omega-3 Fish Oil instead of the prescribed two capsules, and errors were also noted involving an antidepressant, acid reflux medication, and eye drops.

The facility failed to administer medications as ordered for 2 of 4 residents observed during medication passes. Specific errors included incorrect dosing of an antidepressant, an acid reflux medication, a lubricant eye drop, and a triglyceride-lowering supplement.

The facility failed to ensure required staffing hours were met for the assisted living unit on multiple dates in July 2022. Specifically, for a census of 57 residents on 07/10/22, the second shift provided only 21 staff hours, resulting in a shortage of 7 hours.

The facility failed to provide the required number of aide duty hours to meet resident needs. Specifically, for a census ranging from 56 to 59 residents, the facility failed to meet required staffing hours for 3 out of 18 shifts on July 10, July 11, and July 31, 2022.

The facility failed to administer medications as ordered and in accordance with facility policies, resulting in a 14% medication error rate. Specific errors included administering the incorrect inhaler to a resident and failing to provide prescribed medications due to them being unavailable. These errors affected multiple residents, including issues with medications for asthma, constipation, and depression.

The facility failed to administer medications as ordered and in accordance with facility policies for several residents. Specifically, a medication aide administered a ProAir inhaler instead of the prescribed Symbicort to a resident, and other residents were missing medications due to unavailability. The medication error rate was identified as 14% during the observed medication pass.