Inspection Reports for Navion of New Bern
1336 S Glenburnie Rd, New Bern, NC 28562, United States, NC, 28562
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Nov 26, 2024 | 99.25 | 6.25 | 0 | Follow-Up Inspection | |
| Sep 16, 2024 | 93 | 4.5 | 11.5 | Annual Inspection | |
| Aug 10, 2022 | 86.5 | 2.5 | 16 | Annual Inspection | |
| May 26, 2020 | 95 | 2.5 | 7.5 | Annual Inspection | |
| Feb 16, 2017 | 95 | 5 | 0 | Annual Inspection | |
| Apr 18, 2016 | 77 | 13.75 | 0 | Follow-Up Inspection | |
| Feb 2, 2016 | 63.25 | 3.75 | 29.5 | Follow-Up Inspection | |
| Sep 23, 2015 | 89 | 4.5 | 15.5 | Annual Inspection | |
| Jun 11, 2013 | 104.5 | 4.5 | 0 | Annual Inspection | |
| Apr 6, 2011 | 102.5 | 2.5 | 0 | Annual Inspection | |
| May 18, 2010 | 102.5 | 4.5 | 2 | Annual Inspection | |
| Mar 31, 2009 | 102.5 | 4.5 | 2 | Annual Inspection |
Inspection Report
Follow-Up
Deficiencies: 0
Jan 8, 2025
Visit Reason
Report of a Construction Section Biennial Follow-Up Survey conducted on January 8, 2025.
Findings
All deficiencies have been corrected. No further action required.
Inspection Report
Annual Inspection
Deficiencies: 5
Aug 22, 2024
Visit Reason
The Adult Care Licensure Section conducted an Annual and Follow up survey on 08/21/24 through 08/22/24 to assess compliance with health care referral, licensed health professional support, medication administration, and infection control measures.
Findings
The facility failed to ensure proper health care referrals and follow-up for residents, quarterly licensed health professional support reviews were incomplete, multiple medication administration errors occurred including incorrect dosages and missed doses, and infection control measures were not followed during medication administration.
Severity Breakdown
Type B Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure health care referral and follow-up for 2 of 3 sampled residents related to not scheduling a referral for physical therapy and failing to send a fingerstick blood sugar reading log to the provider as requested. | — |
| Failed to ensure quarterly licensed health professional support reviews included physical assessment, evaluation of care provided, and recommendations for 3 of 3 sampled residents. | — |
| Failed to ensure medications were administered as ordered for multiple residents including errors with yeast infection medication, cholesterol medication, bacterial infection medication, bone density supplement, high phosphorus medication, and insulin. | — |
| Failed to ensure medication administration records were accurate for a resident including inaccurate documentation of fenofibrate dosage. | — |
| Failed to ensure medications were administered in accordance with infection control measures; medication aide did not sanitize or wash hands between medication preparations and administrations, did not wear gloves when administering eye drops, and handled medications improperly. | Type B Violation |
Report Facts
Medication error rate: 11
Missed medication doses: 23
Missed medication doses: 13
Missed medication doses: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for medication cart audits, medication administration, and order tracking |
| Director of Clinical Services | Director of Clinical Services (DCS) | Responsible for reviewing LHPS, medication orders, and infection control oversight |
| Medication Aide | Medication Aide (MA) | Administered medications, responsible for ordering insulin, and observed failing to follow infection control measures |
Inspection Report
Annual Inspection
Deficiencies: 8
Jun 23, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from June 22, 2022 to June 23, 2022 to assess compliance with state regulations for an adult care home.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis testing upon admission, inadequate referral and follow-up for residents' health care needs, failure to implement physician orders, lack of therapeutic diet menus, medication administration errors including incomplete antibiotic courses and inaccurate medication administration records, failure to follow infection control measures during medication administration, and improper medication storage with unlocked medication carts and unsecured medications.
Deficiencies (8)
| Description |
|---|
| Failure to ensure tuberculosis testing for 1 of 5 sampled residents upon admission. |
| Failure to ensure referral and follow-up for 2 of 5 residents including notifying PCP of a large bump and scheduling follow-up appointment after hospital discharge. |
| Failure to implement physician orders for compression stockings and every other day weights for 2 of 5 residents. |
| Failure to ensure therapeutic diet menus were available for guidance of food service staff for 3 of 5 sampled residents with specialized diet orders. |
| Failure to administer medications as ordered for 1 of 5 residents including incomplete antibiotic course and failure to update medication orders from scheduled to as needed. |
| Medication administration records were inaccurate and incomplete for 2 of 5 residents including missing steroid tapering dose and multiple medications left undocumented. |
| Failure to implement infection control measures during medication administration by medication aide who did not sanitize or wash hands between residents. |
| Failure to ensure medications were locked when not under direct supervision including unlocked medication cart and insulin left unsecured on top of the cart. |
Report Facts
Residents sampled: 5
Antibiotic doses missed: 1
Medrol dose pack tablets dispensed: 21
Medications with missing documentation: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Facility Nurse | Named in multiple findings including TB testing responsibility, medication administration oversight, and infection control |
| Administrator | Facility Administrator | Named in multiple findings including oversight of TB testing, medication administration, infection control, and medication storage |
| Medication Aide | Named in findings related to medication administration errors and infection control breaches | |
| Lead Cook | Named in findings related to therapeutic diet menu availability and meal preparation | |
| Private Sitter | Named in findings related to failure to apply compression stockings |
Inspection Report
Annual Inspection
Deficiencies: 4
Feb 5, 2020
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility from February 5 to 7, 2020 to assess compliance with applicable regulations.
Findings
The facility was found to have multiple deficiencies including failure to protect food from contamination due to improper labeling and storage, and failure to administer medications as ordered, including missed administration of eye and ear drops and improper infection control practices during medication administration.
Severity Breakdown
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Foods being stored, prepared, and served were not protected from contamination due to exposed and expired food items and opened and undated food containers. | — |
| Failed to administer medications as ordered by a prescribing practitioner to 2 of 5 residents observed, including missed administration of artificial tears and incorrect dosing of ear drops. | — |
| Medications were not administered in accordance with infection control measures, including administering a nasal spray from an opened container labeled for another resident. | Type B Violation |
| Failed to ensure residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to medication administration infection control measures. | — |
Report Facts
Medication error rate: 11
Dates of medication administration: 8
Number of decaying onions found: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Manager | Kitchen Manager | Responsible for overseeing dietary department and ensuring proper food storage and labeling |
| Medication Aide | Medication Aide | Involved in medication administration errors including missed eye drops and incorrect ear drop dosing |
| Health and Wellness Director | Health and Wellness Director | Provided information on medication administration procedures and oversight |
| Executive Director | Executive Director | Provided information on dietary and medication administration expectations |
Inspection Report
Capacity: 60
Deficiencies: 10
Nov 6, 2019
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 (1997 Revision 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 code compliance, including failure of door locking and alarm systems, use of throw rugs, damaged walls, non-operational emergency lighting, fire safety equipment issues, blocked or held-open fire doors, electrical hazards, and lack of exhaust ventilation in specified areas.
Deficiencies (10)
| Description |
|---|
| Front door did not alarm or release within 15 seconds when force applied; service hall exit door lacked required signage. |
| Throw rugs were found in use in the facility, including at the 800 Hall exit door. |
| Walls were not kept in good repair; a 6 inch hole was found in the laundry room wall behind the washer. |
| Electrical emergency/safety lighting equipment not maintained; dining room emergency lights did not illuminate on test. |
| Fire safety equipment not maintained; cross corridor door near Activity Room did not latch on fire alarm activation. |
| Fire doors were blocked or held open by unapproved devices; kickdown on Staff Break Room door and wedged device on Room 104 door. |
| Laundry room door did not close and latch without excessive force. |
| Holes or gaps in fire resistant ceilings or walls allowing potential fire/smoke spread; including incorrect sprinkler head and holes in porch ceiling, fan cover gap in spa, holes in storage ceiling, warped electrical panel frames, and hole near sprinkler head at 800 Hall. |
| Electrical receptacle near Med Room sink did not trip when tested, posing shock hazard. |
| Facility did not provide working exhaust ventilation in laundry room and employee restroom. |
Report Facts
Total licensed capacity: 60
Inspection Report
Follow-Up
Deficiencies: 1
Mar 20, 2018
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies.
Findings
A deficiency related to fire safety equipment was not corrected; specifically, a broken automatic flush bolt on the inactive leaf of a door pair in the gallery prevented the doors from latching properly, potentially exposing occupants to smoke or fire.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the facility's fire safety equipment in a safe operating condition due to a broken automatic flush bolt on the inactive leaf of the right pair of doors in the gallery, causing doors not to latch. |
Inspection Report
Follow-Up
Deficiencies: 3
Feb 7, 2018
Visit Reason
The visit was a Biennial Follow Up Construction Survey conducted to assess compliance with building and fire safety codes.
Findings
The facility failed to meet building code requirements as doors equipped with locking devices did not unlock upon activation of the fire alarm. Additionally, fire safety equipment was not maintained in a safe operating condition, including broken automatic flush bolts on doors that prevented proper latching.
Deficiencies (3)
| Description |
|---|
| Delayed egress exit doors equipped with magnetic locks did not unlock upon activation of the fire alarm. |
| Failure to maintain fire safety equipment in a safe operating condition, including doors that do not completely close and latch. |
| Broken automatic flush bolt on the inactive leaf of the right pair of doors opening to the central common area, preventing doors from latching. |
Report Facts
Number of doors investigated by vendor: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding building code and fire safety equipment deficiencies. |
Inspection Report
Capacity: 60
Deficiencies: 3
Nov 2, 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 (1997 Revision 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 facility failed to meet building code requirements related to fire safety, including delayed egress exit doors not unlocking upon fire alarm activation, fire resistant doors not latching properly, and emergency lighting not functioning on battery power in multiple locations.
Deficiencies (3)
| Description |
|---|
| Delayed egress exit doors equipped with magnetic locks did not unlock upon activation of the fire alarm. |
| Fire resistant rated doors adjacent to Room #101 and gallery doors did not latch to remain shut when closed. |
| Failure to maintain electrical emergency/safety lighting equipment in safe operating condition; multiple emergency lights did not illuminate when tested on battery power. |
Report Facts
Licensed capacity: 60
Inspection Report
Follow-Up
Deficiencies: 4
Apr 6, 2016
Visit Reason
This report is of a follow-up survey conducted to verify correction of previously identified deficiencies at Brookdale New Bern.
Findings
The follow-up survey revealed that not all deficiencies were corrected. Observations included unsecured oxygen cylinders, malfunctioning locking systems on exit doors, non-operational emergency lights, burned out exit sign bulbs, and doors that did not completely close and latch.
Deficiencies (4)
| Description |
|---|
| Storage of oxygen bottles was not maintained in a manner that keeps the facility free from hazards; oxygen cylinders in rooms 605 and 106 were not secured in approved holders. |
| Facility's locking system was not maintained to keep the facility free from hazards; exit door adjacent to salon would not re-lock after emergency release test, and staff did not have a key for the keyed override switch on the service corridor exit door. |
| Failure to have electrical emergency/life safety related equipment in operating condition; emergency light #5 in Kitchen Service Hall did not work on battery power, some exit sign bulbs near room 205 were burned out and not fully illuminated. |
| Failure to maintain fire safety/life safety equipment in safe operating condition; doors did not completely close and latch including dining room cross corridor smoke doors and door in 300 Hall, Room 301 lacked locking hardware. |
Inspection Report
Routine
Capacity: 60
Deficiencies: 10
Jan 21, 2016
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 (1997 Revision) 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 fire marshal inspection report, fire safety hazards such as doors being blocked open, improper storage of oxygen bottles, malfunctioning locking systems, failure to maintain electrical fire emergency and life safety equipment, doors not closing and latching properly, and use of prohibited portable unvented electrical heaters.
Deficiencies (10)
| Description |
|---|
| Facility failed to have a current fire marshal's inspection report available for review. |
| Fire safety components not maintained; doors blocked open or held open by unapproved devices. |
| Oxygen bottles stored improperly without restraining devices or racks. |
| Magnetic lock for exit door adjacent to salon would not re-lock after emergency release test. |
| Ceiling smoke detector detached from its base with visible wiring. |
| Multiple wall mounted emergency lights did not work on battery power; some exit sign bulbs burned out. |
| Doors did not completely close and latch, limiting ability to contain smoke or fire. |
| Door coordinator for cross corridor smoke doors adjacent to restrooms and sunroom did not function correctly. |
| No lock hardware set installed on door in Room 301. |
| Use of portable unvented electrical heater found in director's office, which is prohibited. |
Report Facts
Total licensed beds: 60
Oxygen cylinders improperly stored: 6
Emergency lights not working: 5
Inspection Report
Deficiencies: 7
Dec 15, 2015
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey to assess compliance with prior deficiencies and resident care.
Findings
The facility failed to complete timely resident assessments following significant changes in condition, provide adequate supervision to prevent falls, ensure proper referral and follow-up for health care needs, implement physician orders including medication administration and treatments, and properly use physical restraints. Multiple residents experienced falls, injuries, and inadequate care coordination. Documentation and communication deficiencies were also noted.
Severity Breakdown
Type A1: 1
Type B: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to complete resident assessments within 10 days following significant changes in condition for residents #1 and #3. | — |
| Failure to provide supervision in accordance with assessed needs, care plans, and symptoms for residents with multiple falls resulting in injuries. | Type A1 |
| Failure to assure referral and follow-up to meet routine and acute health care needs for residents #1, #2, #3, and #4 including failure to seek medical evaluation after falls, notify physicians of side effects, and coordinate transportation. | Type B |
| Failure to implement physician orders for daily weights, dressing changes, CPAP use, incentive spirometry, and bowel movement monitoring for residents #1, #3, #4. | Type B |
| Failure to complete required Licensed Health Professional Support (LHPS) reviews including physical assessments and care plan evaluations for residents #1, #4, and #5. | Type B |
| Failure to administer medications as ordered including insulin sliding scale, oral diabetes medication, inhaler use, and stomach ulcer medication for residents #2, #6, #7, #8. | Type B |
| Use of physical restraints including an unplugged lift chair without proper assessment, care planning, physician order, or alternatives for resident #4. | — |
Report Facts
Medication errors: 4
Resident falls: 13
Weight gain: 9
Blood sugar readings: 511
Medication administration errors: 11
Medication administration errors: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Responsible for resident assessments, care plans, LHPS reviews, and communication with physicians; involved in supervision and restraint decisions. |
| Executive Director | Executive Director | Responsible for facility operation and oversight; communicated with Health and Wellness Director and staff regarding care and supervision. |
| Physical Therapist | Contracted Physical Therapist | Provided therapy services; reported concerns about fall interventions and resident safety; communicated with physicians and family. |
| Resident Care Coordinator | Resident Care Coordinator | Responsible for care plans, assignment sheets, and communication of resident care needs. |
| Medication Aide | Medication Aide | Administered medications; involved in medication errors and communication of orders. |
Inspection Report
Annual Inspection
Deficiencies: 4
Aug 21, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale New Bern from August 19-21, 2015 to assess compliance with health care regulations.
Findings
The facility failed to notify the physician of increased leg swelling and redness for Resident #1, failed to schedule timely follow-up appointments, and failed to make a dermatology appointment for excessive dry skin and warts. Additionally, the facility failed to assure documentation and implementation of physician's orders for TED hose for Residents #3 and #4, and failed to assure medications were administered as ordered for Residents #1 and #6, including medication errors and refusals.
Severity Breakdown
Type A2 Violation: 1
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to notify physician of increased leg swelling and redness and failed to schedule follow-up appointments for Resident #1. | Type A2 Violation |
| Facility failed to assure documentation and implementation of physician's orders for TED hose for Residents #3 and #4. | — |
| Facility failed to assure medications were administered as ordered, including medication errors and refusals for Residents #1 and #6. | Type B Violation |
| Facility failed to assure every resident had the right to receive care and services which are adequate, appropriate, and in compliance with relevant laws and rules. | — |
Report Facts
Medication error rate: 11
Residents sampled: 5
Residents sampled: 14
Residents sampled: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Registered Nurse | Named in findings related to failure to notify physician and follow-up on resident conditions, and responsible for reviewing shift notes and referrals. |
| Executive Director | Named in findings related to notification responsibilities and review of shift reports. | |
| Licensed Practical Nurse | Involved in communication with physician's office regarding orders and medication administration. | |
| Medication Aide | Interviewed regarding medication administration and resident care. | |
| Resident Care Coordinator | Responsible for reviewing shift reports and documenting concerns. |
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 8
Aug 21, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey to assess compliance with health care, medication administration, and resident rights regulations.
Findings
The facility failed to notify the physician timely about a resident's leg wound condition, failed to schedule follow-up appointments, and did not make a dermatology appointment for a resident. Medication administration errors were found including improper dosing, lack of documentation, and failure to follow physician orders. One resident was inadequately supervised related to wandering behavior. Hot water temperatures in the Special Care Unit exceeded regulatory limits. Housekeeping and maintenance issues were noted including stained carpets and peeling paint.
Severity Breakdown
Type A2 Violation: 1
Type B Violation: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to notify physician of increased leg swelling and redness around a leg wound until at least 8 days after swelling and pain were documented; failed to schedule follow-up appointment after emergency room visit; failed to make dermatology appointment for excessive dry skin/flaking and warts on left arm and hand for 1 of 5 residents. | Type A2 Violation |
| Failed to assure medications were administered as ordered including errors with antibiotic for dental procedure, antibiotic eye ointment, topical gel for pain, pain medication, diuretic for swelling, potassium supplement, and topical antibiotic ointments for 2 of 14 residents observed during medication passes and 2 of 5 residents sampled. | Type B Violation |
| Failed to assure every resident had the right to receive care and services which are adequate, appropriate, and in compliance with laws and regulations related to health care and medication administration. | — |
| Failed to assure walls and floors were clean and in good repair in 15 resident bedrooms with multiple carpet stains and peeling paint. | — |
| Failed to assure there were sufficient staff to perform laundry, housekeeping, and kitchen duties in addition to attending to residents' personal care needs. | — |
| Failed to assure 1 of 5 sampled residents was adequately supervised in accordance with assessed needs related to wandering behavior and removal of wander management system. | Type B Violation |
| Failed to assure hot water temperatures in the Special Care Unit were maintained between 100 and 116 degrees Fahrenheit at all fixtures accessible to residents; temperatures up to 122.5 degrees F were observed. | — |
| Failed to assure 1 of 5 sampled staff had a criminal background check in accordance with state law. | — |
Report Facts
Medication error rate: 11
Residents present: 61
Hot water temperature: 122.5
Hot water temperature: 119.6
Hot water temperature: 120.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide | No criminal background check on file |
| Health and Wellness Director | Registered Nurse | Named in multiple findings related to medication administration and resident care |
| Resident Care Coordinator | Named in multiple findings related to medication administration and resident care | |
| Executive Director | Named in multiple findings related to facility operations and compliance |
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