Inspection Reports for Navion of Shelby
1425 E Marion St, Shelby, NC 28150, United States, NC, 28150
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Moderate
Unclassified
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Jun 12, 2023 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Mar 18, 2022 | 103.5 | 3.5 | 0 | Annual Inspection | |
| Jun 5, 2019 | 101 | 5 | 0 | Follow-Up Inspection | |
| Mar 11, 2019 | 96 | 5.5 | 9.5 | Annual Inspection | |
| Aug 9, 2016 | 103.5 | 3.5 | 0 | Annual Inspection | |
| Dec 5, 2013 | 104.5 | 4.5 | 0 | Annual Inspection | |
| Sep 6, 2011 | 100.5 | 4.5 | 4 | Annual Inspection | |
| Jul 14, 2010 | 104.5 | 4.5 | 0 | Annual Inspection | |
| May 21, 2009 | 104.5 | 4.5 | 0 | Annual Inspection |
Inspection Report
Annual Inspection
Deficiencies: 1
May 4, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey of the facility from May 3, 2023 to May 4, 2023 to assess compliance with health care regulations.
Findings
The facility failed to ensure referral and follow-up for one resident who had orders for podiatry, physical therapy, and occupational therapy referrals. The resident's toenail condition was observed to be severe and painful, but appropriate referrals and follow-up care were delayed or not made in a timely manner.
Deficiencies (1)
| Description |
|---|
| Failed to ensure referral and follow-up for 1 of 5 sampled residents who had an order for podiatry referral due to thickened, yellow and painful toenails and a referral for physical therapy and occupational therapy. |
Report Facts
Number of sampled residents with referral issues: 1
Dates of survey: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Health and Wellness Director | Provided emails and information regarding referral process and delays |
| Therapy Manager | Therapy Manager | Communicated about receipt and processing of therapy orders |
| Administrator | Administrator | Interviewed regarding knowledge of referral processes and expectations |
Inspection Report
Follow-Up
Deficiencies: 3
Oct 18, 2019
Visit Reason
The visit was a biennial follow-up construction survey to verify correction of previously identified deficiencies related to building and fire safety compliance.
Findings
The facility failed to correct all deficiencies; issues included a barely audible delayed egress audible signal, corridor doors that did not close and latch properly to resist fire and smoke, and improper storage too close to a fire sprinkler head.
Deficiencies (3)
| Description |
|---|
| Delayed Egress exit signal was barely audible, failing to assure proper operation. |
| Corridor doors near the Administrator's office and room 404 dragged the floor and would not close when activated by the fire alarm system, risking fire and smoke spread. |
| Items were stored within 6 inches of the fire sprinkler head, violating the required 18-inch clearance and potentially negating fire sprinkler effectiveness. |
Report Facts
Clearance distance: 6
Survey date: Oct 18, 2019
Inspection Report
Capacity: 60
Deficiencies: 7
Sep 19, 2019
Visit Reason
The facility was surveyed for conformance with the 1996 Rules for the Licensing of Adult Care Homes, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina Building Code for Institutional Unrestrained Occupancies during a Construction Section Biennial Survey.
Findings
Multiple deficiencies were identified including delayed egress doors not functioning properly, improper handling and storage of portable medical oxygen cylinders, corridor doors not closing and latching properly to resist fire and smoke, improper storage near fire sprinkler heads, and a bathroom with a leaking toilet.
Deficiencies (7)
| Description |
|---|
| Delayed Egress exit door at the front door would not release and open as required by the NC State Building Code; the door required more than 100 pounds of force to open instead of the maximum 15 pounds. |
| Facility failed to have all required components for doors with Delayed Egress Locking; the audible signal was barely audible at the Delayed Egress exit from the Dining room. |
| Building was not maintained in a safe manner by not properly handling portable medical oxygen cylinders; two cylinders stored without containers or racks, two stored in a cardboard box, and an unapproved beverage crate found in oxygen storage room. |
| Corridor doors prevented from closing quickly and latching, including smoke barrier doors dragging the floor and a kitchen door tied open (corrected during survey). |
| Delayed egress exit door near the kitchen would not relock after being tested, potentially allowing residents to elope. |
| Improper storage too close to a fire sprinkler head; items stacked within 6 inches of the ceiling in the sales closet, violating the required 18-inch clearance. |
| Bathroom near the dining room marked 'Out of Order' due to a leaking toilet that caused a puddle on the floor. |
Report Facts
Facility licensed capacity: 60
Force required to open delayed egress door: 100
Required maximum force to open delayed egress door: 15
Storage clearance below sprinkler head: 18
Actual storage clearance below sprinkler head: 6
Inspection Report
Annual Inspection
Deficiencies: 4
Nov 5, 2018
Visit Reason
The Adult Care Licensure Section conducted an annual survey on October 30 and 31, 2018 with a telephone exit date of November 5, 2018.
Findings
The facility failed to assure proper notification of primary care provider regarding abnormal fingerstick blood sugar (FSBS) results, failed to implement physician orders for FSBS checks and medication patch placement, failed to assure accurate documentation of FSBS on electronic Medication Administration Records (eMAR), and failed to implement infection control policies consistent with CDC guidelines regarding glucometer use.
Severity Breakdown
Type B Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to assure the primary care provider was notified regarding FSBS results outside ordered parameters for 1 of 5 residents (Resident #1). | — |
| Failed to implement physicians' orders for FSBS checks for Resident #1 and placement of a medicine patch for Resident #5. | — |
| Failed to assure accurate documentation on the eMAR for FSBS for Residents #1 and #6. | — |
| Failed to implement infection control policy consistent with CDC guidelines for glucometer use, resulting in shared use of glucometers for Residents #1 and #6. | Type B Violation |
Report Facts
FSBS documented low readings: 9
Exelon patch administration: 30
Residents requiring FSBS checks: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator (RCC) | Responsible for training medication aides and auditing eMARs and glucometers; interviewed multiple times regarding FSBS and documentation issues. | |
| Administrator | Interviewed regarding staff knowledge and oversight of FSBS notification, documentation, and infection control policies. | |
| Medication Aides (MAs) | Multiple medication aides interviewed regarding FSBS checks, notification, documentation, and glucometer use. | |
| Health and Wellness Director (HWD) | Designated to audit eMARs and glucometers but was a new employee and had not been assigned the task. | |
| Certified Medical Assistant (CMA) for Resident #1's PCP | Provided expectations for FSBS notification and follow-up. | |
| Executive Director (ED) | Responsible for auditing eMARs monthly and discussed medication patch placement with family and physician. |
Inspection Report
Capacity: 60
Deficiencies: 7
Jun 21, 2017
Visit Reason
The facility was surveyed for conformance with the 1996 Rules for the Licensing of Adult Care Homes, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina Building Code for Institutional Unrestrained Occupancies as part of a Construction Section Biennial Survey.
Findings
Multiple deficiencies were identified including a delayed egress exit door requiring excessive force to open, obstructed exit path from the dining room, inadequate documentation of fire safety rehearsals, non-functioning smoke detector near bedroom 801, corridor doors that do not close or latch properly, an emergency light hanging down by wires, and unsealed penetrations compromising the one-hour fire rated ceiling.
Deficiencies (7)
| Description |
|---|
| Delayed Egress exit at the front door did not initiate the egress process even after a force of approximately 100 pounds was applied. |
| Exit to the exterior from the dining room was obstructed with a table and 2 chairs. |
| Records of fire safety rehearsals included little to no description of what the rehearsal involved. |
| Corridor smoke detector near bedroom 801 failed to activate when tested with smoke. |
| Many corridor doors prevented from closing quickly and latching, including double doors to dining room not latching and having gaps, door to bedroom 705 hard to latch, and door to beauty salon 19 propped open. |
| Emergency light on ceiling near room 101 partially hanging down by wires. |
| Required one-hour fire rated ceiling compromised by unsealed penetration for wires in the Administrator's office. |
Report Facts
Facility licensed capacity: 60
Force applied to delayed egress door: 100
Gap between double doors: 0.1875
Gap between double doors: 0.4375
Inspection Report
Capacity: 60
Deficiencies: 8
Jun 9, 2015
Visit Reason
Biennial Construction Survey to assess conformance with the 1996 Rules for the Licensing of Adult Care Homes, applicable portions of the 2005 Rules for Adult Care Homes of Seven or More Beds, and the 1996 North Carolina Building Code for Institutional Unrestrained Occupancies.
Findings
The survey found multiple deficiencies including compromised one-hour fire rated walls and ceilings with unsealed holes in various locations, a cross-corridor door that failed to latch during fire alarm activation, improper storage of portable medical oxygen cylinders, and lack of hand grips in the shower area presenting safety hazards.
Deficiencies (8)
| Description |
|---|
| Holes in ceiling of kitchen compromising fire rated construction. |
| Holes in wall and ceiling of mop closet off the kitchen compromising fire rated construction. |
| Holes in ceiling of Mechanical room 400 compromising fire rated construction. |
| Hole in ceiling at nurse station compromising fire rated construction. |
| Hole beside sprinkler escutcheon in ceiling of corridor near room 407 compromising fire rated construction. |
| Cross-corridor door on 400 Hall failed to latch closed during fire alarm activation. |
| Portable medical oxygen cylinders stored without container or rack, posing safety hazard. |
| No hand grip provided at the shower in the Garden Spa, presenting a fall hazard. |
Report Facts
Facility licensed capacity: 60
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