Inspection Reports for Navion of Greenville
2105 W Arlington Blvd, Greenville, NC 27834, United States, NC, 27834
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Inspection Report
Follow-Up
Deficiencies: 3
May 7, 2025
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey from May 6, 2025 to May 7, 2025 to verify correction of previous deficiencies.
Findings
The facility was found deficient in ensuring timely referral and follow-up for mental health services for Resident #4, clarifying medication orders for Resident #3 related to blood pressure management, and ensuring observation of medication administration for Resident #2. These deficiencies involved failure to schedule timely mental health appointments, unclear medication orders, and failure to observe residents taking medications.
Deficiencies (3)
| Description |
|---|
| Failed to ensure referral and follow-up to meet the acute health care needs of Resident #4 related to failing to ensure an order for referral to mental health was completed. |
| Failed to clarify medication orders for Resident #3 for blood pressure checks, including unclear instructions on medications to resume and parameters. |
| Failed to ensure Resident #2 was observed taking medication, resulting in a medication being left behind and not taken immediately. |
Report Facts
Sampled residents: 5
New patient appointment delay: 3
New patient appointment scheduled: 1
Medications scheduled: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Responsible for ensuring referrals were completed; failed to follow up on mental health referral for Resident #4 | |
| Administrator | Responsible for RCC duties during absence; acknowledged missed mental health referral and medication order clarification issues | |
| Medication Aide | Administered medications; failed to observe Resident #2 taking medication fully | |
| Primary Care Provider | Ordered mental health referral for Resident #4 and blood pressure medication orders for Resident #3 |
Inspection Report
Annual Inspection
Deficiencies: 3
Feb 14, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and follow up survey from February 12, 2025 to February 14, 2025.
Findings
The facility failed to provide adequate supervision for two high fall risk residents resulting in multiple falls and hospitalizations. Additionally, the facility failed to ensure referral and follow-up for a resident with significant weight loss and failed to implement physician orders for daily blood pressure monitoring and notification.
Severity Breakdown
Type B Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide supervision for 2 of 5 sampled residents resulting in multiple falls and hospitalizations. | Type B Violation |
| Failed to ensure referral and follow-up for a resident with a 14% weight loss in one month. | — |
| Failed to ensure implementation of orders for daily blood pressure checks and notification to PCP for elevated readings. | — |
Report Facts
Falls: 13
Falls: 4
Weight loss percentage: 14
Weight loss in pounds: 17.2
Blood pressure readings over 160/100: 10
Inspection Report
Follow-Up
Deficiencies: 0
Nov 21, 2024
Visit Reason
Report of a Biennial Follow Up Construction Survey conducted on November 21, 2024.
Findings
Deficiencies noted during the Biennial Construction Survey have been corrected and no further action is required at this time.
Inspection Report
Annual Inspection
Deficiencies: 2
Mar 15, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey and a follow-up survey on 03/14/23 to 03/15/23 to assess compliance with health care and medication administration regulations.
Findings
The facility failed to implement physician orders for daily blood pressure checks for one resident and failed to administer medications correctly for multiple residents, including errors in dosage and missed administrations of prescribed medications.
Deficiencies (2)
| Description |
|---|
| Failed to ensure implementation of orders for daily blood pressure checks for Resident #1. |
| Failed to administer medications as ordered for Residents #3, #4, and #5, including incorrect dosages and missed administrations of blood thinner, supplement, diuretic, thyroid medication, and iron supplement. |
Report Facts
Medication error rate: 10
Missed doses of levothyroxine sodium: 19
Missed doses of ferrous sulfate: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for entering orders on eMAR and involved in interviews regarding medication administration and blood pressure check deficiencies |
| Health and Wellness Director | Health and Wellness Director (HWD) | Responsible for entering orders on eMAR; had not worked at the facility since 03/08/23 |
| Clinical Services Specialist Nurse | Corporate Clinical Services Specialist Nurse (CSSN) | Interviewed regarding responsibility for entering PCP orders and medication administration |
| Administrator | Administrator | Interviewed regarding medication administration errors and potential harm to residents |
| Medication Aide | Medication Aide (MA) | Observed administering medications and interviewed regarding medication errors |
| Corporate Nurse | Corporate Nurse | Interviewed regarding medication administration expectations and facility staffing |
Inspection Report
Annual Inspection
Deficiencies: 3
Jun 25, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey, a follow-up survey, and two complaint investigations from 06/23/21 to 06/25/21. The complaint investigations were initiated by the Pitt County Department of Social Services on 03/08/21 and 06/16/21.
Findings
The facility failed to ensure tuberculosis testing upon admission for one resident, failed to complete quarterly Licensed Health Professional Support evaluations for two residents, and failed to maintain clean and uncontaminated kitchen and food storage areas with expired food items present.
Complaint Details
The complaint investigations were initiated by the Pitt County Department of Social Services on 03/08/21 and 06/16/21.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure 1 of 3 sampled residents was tested for tuberculosis disease upon admission in compliance with control measures. |
| Facility failed to ensure quarterly Licensed Health Professional Support evaluations were completed for 2 of 3 sampled residents with specific care tasks. |
| Facility failed to ensure kitchen and food storage areas were clean and free of contamination related to expired food items including milk, bread, and refrigerated vegetables. |
Report Facts
Inspection score: 96
Number of sampled residents not tested for TB: 1
Number of sampled residents missing quarterly LHPS evaluations: 2
Expired milk jugs: 2
Expired lettuce bags: 2
Expired shredded carrot bags: 2
Expired bread loaves: 2
Expired sandwich buns package: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Specialty | Interviewed regarding TB testing and Licensed Health Professional Support evaluations; acting as facility nurse temporarily | |
| Executive Director | Interviewed regarding nurse responsibilities, compliance tracker access, and kitchen oversight | |
| Personal Care Aide | Interviewed about Resident #2's transfer assistance and sling use | |
| Cook | Interviewed about food preparation and expired food items in kitchen |
Inspection Report
Plan of Correction
Capacity: 60
Deficiencies: 11
Jan 15, 2020
Visit Reason
Biennial Construction Survey conducted to assess conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, applicable North Carolina Building Codes, and Minimum Standards and Regulations for Homes for the Aged.
Findings
Multiple physical plant deficiencies were identified including malfunctioning exit door locking system, inadequate heating and blocked combustion air vents in the sprinkler riser room, unsafe outside premises, poor housekeeping and furnishings maintenance, failure to maintain electrical emergency lighting, unsafe plumbing configurations, and fire safety system deficiencies such as doors not closing properly and gaps in fire-resistant ceilings.
Deficiencies (11)
| Description |
|---|
| Exit doors operate on a 15 second delay locking system that did not activate on the main entry door and the door did not release when pushed for 15 seconds. |
| Sprinkler riser room lacks heating and combustion air vents were blocked with cardboard and tape to prevent pipes from freezing. |
| Mechanical equipment does not meet requirements; gas water heaters' combustion air vents blocked with cardboard and tape. |
| Outside premises not maintained clean and safe: missing door knob, damaged picnic table, mildew on siding. |
| Walls and furnishings not kept clean and in good repair; door magnets damaged and pulling off wall and door veneer. |
| Ceilings and equipment not kept clean; exhaust fan vent had heavy dust accumulation. |
| Electrical emergency/safety lighting equipment not maintained; multiple emergency lights failed battery test. |
| Plumbing piping lacks minimum 2" air gap; icemaker drain line resting directly on floor drain. |
| Fire safety components not maintained; doors held open with unapproved devices impeding quick closure. |
| Fire safety systems compromised by holes or gaps at penetrations through fire resistant ceilings allowing smoke/fire spread. |
| Fire safety equipment not maintained; warped and separating doors prevented proper closing and latching. |
Report Facts
Licensed capacity: 60
Inspection Report
Annual Inspection
Deficiencies: 4
Dec 12, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility from December 10, 2019 through December 12, 2019 to assess compliance with medication administration, self-administration of medications, controlled substance management, and related regulatory requirements.
Findings
The facility failed to administer medications as ordered for multiple residents, including errors in medication timing, dosage, and medication type. The facility also failed to ensure accurate documentation of medication administration, proper self-administration orders, and proper disposal of expired controlled substances.
Deficiencies (4)
| Description |
|---|
| Failed to administer medications as ordered for 3 of 7 residents observed during medication passes, including errors with diabetic medication, Omega 3 Fish Oil, Parkinson's medication, and wrong dosage of anxiety medication. |
| Failed to ensure electronic Medication Administration Records (eMARs) were accurate, including missing initials of medication aide administering PRN controlled substances for anxiety for one resident. |
| Failed to assure 1 resident who self-administered medications had physician orders to do so and proper assessments were not conducted. |
| Failed to assure expired controlled substance (Ativan) was destroyed or disposed of properly for one resident; expired medication was administered after expiration date. |
Report Facts
Medication error rate: 12
Medication doses administered: 6
Expired Ativan tablets remaining: 113
Expired Ativan tablets administered: 4
Ativan tablets checked in: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator/Medication Aide | Administered medications, involved in medication administration process and interviews regarding medication errors and documentation. |
| Health and Wellness Director | Registered Nurse | Responsible for medication administration oversight, medication order accuracy, and self-administration assessments. |
| Medication Aide | Administered medications including PRN controlled substances and involved in documentation discrepancies. | |
| Executive Director | Oversight of facility expectations for medication administration and documentation. |
Inspection Report
Capacity: 60
Deficiencies: 9
Jan 31, 2018
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 North Carolina Building Code and Minimum Standards and Regulations for Homes for the Aged in effect at time of initial licensure, as part of a Biennial Construction Survey.
Findings
Multiple physical plant deficiencies were noted including failure of delayed egress doors to operate properly, ceilings and walls not kept clean or in good repair, fire safety systems and electrical equipment not maintained in safe operating condition, failure to maintain fire safety components such as door latches and sprinkler head penetrations, and failure to provide required exhaust ventilation in certain areas.
Deficiencies (9)
| Description |
|---|
| Delayed egress at main entrance doors did not start unlocking when pushed; 200 Hall exit delayed egress released after 15 seconds with weak alarm volume. |
| Ceilings not kept clean and in good repair; water stain with black mildew in dining room; ceiling finish bubbled and peeling in corridor outside Room 408; dust and lint accumulation in laundry room ceiling vents. |
| Walls and doors not maintained in good repair; missing wood trim on dining room exit door; damaged wood base in Room 101; hole in exterior wall behind industrial dryer; damaged light switch cover plate in main laundry; mold and mildew around electrical panel in mechanical room. |
| Failure to maintain building's fire safety systems; gaps around sprinkler heads in multiple locations; unfinished ceiling repairs and unsecured exhaust flange in riser room. |
| Emergency lights outside front office, Life Enrichment Coordinator's office, Room 408, and Room 704 did not illuminate when tested. |
| Door to Beauty Salon propped open with rubber wedge impeding quick closure. |
| Nurses' station magnetic override switch cover box fallen off leaving exposed wires. |
| Right leaf on cross corridor doors by guest bathroom did not latch when released at fire alarm activation; magnet not secure. |
| Facility failed to provide exhaust ventilation at required rate in specified spaces; exhaust fans in main laundry areas not working. |
Report Facts
Total licensed capacity: 60
Inspection Report
Capacity: 60
Deficiencies: 14
Mar 16, 2016
Visit Reason
Biennial Construction Survey conducted to assess conformance with applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, North Carolina Building Code, and Minimum Standards and Regulations for Homes for the Aged.
Findings
Multiple physical plant deficiencies were identified including failure to meet building code requirements for delayed egress locking system, unclean and disrepair conditions, improperly maintained fire extinguishers, non-functional emergency lighting, compromised fire-resistance-rated construction, unsafe electrical power system conditions, impaired fire sprinkler heads and escutcheon plates, lack of proper maintenance and documentation of fire safety equipment, obstructed fire sprinkler heads, inadequate commercial kitchen hood fire extinguishing system inspections, and ventilation system failures.
Deficiencies (14)
| Description |
|---|
| Building failed to meet NC State Building Code for delayed egress locking system components. |
| Facility failed to provide clean environment; loose connection of commode to floor in Bedroom 203. |
| Fire extinguishers not properly maintained; monthly inspection documentation stopped in January 2016. |
| Emergency lighting did not work on backup power in multiple locations. |
| Holes and gaps in fire-resistance-rated ceiling construction compromising integrity. |
| Unsafe electrical power system conditions including blocked access to electric panels and broken switch/receptacle cover plates. |
| Fire and smoke resistance of hazardous area doors not maintained; door closure removed. |
| Dry fire sprinkler system air compressor frequently cycling to recharge system. |
| Fire sprinkler heads obstructed by stored items and lint/insulation; escutcheon plates damaged or missing. |
| Commercial kitchen hood fire extinguishing system lacked required inspections and documentation. |
| Holes and gaps in fire-resistance-rated wall construction compromising integrity. |
| Corridor doors not smoke resisting; holes and devices holding doors open preventing proper closure. |
| Cross-corridor doors did not close completely or latch to restrict smoke; missing strike plate. |
| Exhaust ventilation system failed to remove required air; ventilation equipment had excessive dust/lint accumulation. |
Report Facts
Licensed capacity: 60
Frequency of fire sprinkler system air compressor cycling: 3
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 4
Nov 19, 2014
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 11/18/14 and 11/19/14 to assess compliance with regulations for Sterling House of Greenville.
Findings
The facility was found deficient in providing adequate personal care for a resident with catheter care needs, failed to provide appropriate snacks three times daily to all residents, had medication administration errors for multiple residents, and did not provide mandatory annual infection prevention training for medication aides.
Deficiencies (4)
| Description |
|---|
| Failed to provide personal care for 1 of 2 residents (#5) requiring assistance with catheter care and hygiene. |
| Failed to assure foods and beverages appropriate to resident diets were offered or made available as snacks three times per day to all residents (census of 47). |
| Failed to assure medications were administered as prescribed for 3 of 5 residents observed during medication administration, with a medication error rate of 24%. |
| Failed to provide mandatory annual infection prevention training for 2 of 2 medication aides employed for more than one year. |
Report Facts
Residents present: 47
Medication error rate: 24
Medication administration observations: 25
Medication aides without infection control training: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Administered Restasis eye drops incorrectly to Resident #7. | |
| Administrator | Interviewed regarding resident care and medication administration issues. | |
| Resident Care Coordinator | Provided information on resident care, medication administration, and staff training. | |
| Executive Director | Interviewed about snack provision and infection control training. | |
| Staff A | Medication Aide/Resident Assistant | Lacked documentation of annual infection control training. |
| Staff B | Medication Aide/Resident Assistant | Lacked documentation of annual infection control training. |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 4
Nov 19, 2014
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Sterling House of Greenville on 11/18/14 and 11/19/14 to assess compliance with adult care home regulations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate personal care for a resident with dementia and catheter care needs, failure to provide appropriate snacks to all residents three times daily, medication administration errors for multiple residents, and failure to provide mandatory annual infection prevention training for medication aides.
Deficiencies (4)
| Description |
|---|
| Failure to provide personal care and catheter care assistance to Resident #5 who has dementia and urinary catheter. |
| Failure to assure foods and beverages appropriate to resident diets were offered or made available as snacks three times per day to all residents (census of 47). |
| Failure to assure medications were administered as prescribed for 3 of 5 residents observed during medication administration, including errors with ophthalmic drops, timing of medications, and medication availability. |
| Failure to provide mandatory annual infection prevention training for 2 of 2 medication aides employed for more than one year. |
Report Facts
Residents present: 47
Medication error rate: 24
Residents interviewed: 11
Residents observed in group activity: 12
Residents interviewed after menu chat meeting: 12
Residents interviewed regarding afternoon snack: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Administered Restasis eye drops incorrectly to Resident #7 and failed to administer Systane Ultra eye drops as ordered. | |
| Medication Aide | Ordered Systane Ultra eye drops after running out and documented medication unavailability. | |
| Resident Care Coordinator | Provided information about Resident #5's care needs and medication administration procedures. | |
| Administrator | Provided information about Resident #5's care plan, medication administration issues, and staffing changes. | |
| Staff A | Medication Aide/Resident Assistant | Employed since 10/19/13; no documentation of annual infection control training. |
| Staff B | Medication Aide/Resident Assistant | Employed since 08/09/2011; no documentation of annual infection control training since 06/12/12. |
| Executive Director | Provided information about snack provision and infection control training scheduling. |
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