Inspection Reports for The Ridge at New Bern

The Adult Care Licensure Section and the Craven County Department of Social Services conducted a follow-up survey from 09/24/25 through 09/26/25 to verify correction of previous deficiencies.

The facility failed to ensure referral and follow-up to meet acute health care needs of residents, failed to serve therapeutic diets as ordered, failed to clarify medication orders, and failed to administer medications as ordered to multiple residents. Infection control measures were also not followed during medication administration.

A Construction Section Biennial Follow-Up survey was conducted to verify correction of previously identified deficiencies.

The facility failed to maintain the outside premises in a safe condition, with findings including a heavily damaged drive-through canopy and multiple large potholes in the parking lot.

The Adult Care Licensure Section and Craven County Department of Social Services conducted an annual, follow-up survey and complaint investigation from June 17 to June 19, 2025, initiated by a complaint on May 28, 2025.

The facility was found deficient in multiple areas including failure to ensure the front entrance door alarm was engaged for residents with dementia and wandering behavior, improper hot water temperature control, failure to meet acute health care needs due to delayed follow-up appointments, failure to serve therapeutic diets as ordered, inadequate feeding assistance, unclear medication orders, inaccurate medication administration records, and failure to follow infection control procedures during meal service.

The complaint investigation was initiated by the Craven County Department of Social Services on May 28, 2025, related to concerns about resident safety and care.

The facility was surveyed for conformance with applicable portions of the Minimum Standards and Regulations for Homes for the Aged and Adult Care Homes, as well as the North Carolina State Building Code, Institutional Occupancy, as part of a Construction Section Biennial survey.

Deficiencies were cited related to failure to meet code requirements for doors equipped with Special Locking due to missing wiring and system component diagrams, and unsafe conditions of the outside premises including damage to the drive-through canopy and multiple large potholes in the parking lot.

The visit was conducted as a complaint investigation related to medication administration and health care practices at The Indigo at New Bern adult care home.

The facility failed to assure proper preparation and administration of medications according to licensed practitioner orders, resulting in a Type A1 violation. Additionally, the facility failed to implement ordered blood sugar checks and failed to assure referral and follow-up of acute health care needs, resulting in Type B violations. These failures led to serious physical harm to a resident and multiple deficiencies in documentation and medication administration.

The complaint investigation was substantiated with findings that the facility failed to administer insulin as ordered, resulting in a resident developing diabetic ketoacidosis (DKA) and requiring hospitalization. The facility also failed to implement ordered blood sugar monitoring and failed to provide appropriate referral and follow-up for acute health care needs.

A Construction Section Biennial Complaint Follow-Up survey was conducted to verify correction of previously identified deficiencies.

All deficiencies identified in the prior complaint survey have been corrected. No further action is required.

This was a follow-up visit triggered by a prior complaint; all deficiencies were corrected.

The inspection was conducted as a complaint investigation regarding the facility's failure to notify a resident's physician of acute changes in the resident's status following a fall.

The facility failed to notify the resident's primary care physician about significant changes in condition and an unwitnessed fall, resulting in substantial risk for serious physical harm. This failure constitutes a Type A2 Violation. The facility provided a plan of protection and an updated plan of correction.

The complaint investigation substantiated that the facility did not notify the resident's primary care physician when the resident, diagnosed with dementia and on anticoagulants, experienced behavioral changes, an unwitnessed fall, and subsequent physical decline. The resident was found with injuries and was not sent to the hospital as per the POA's wishes. The failure to notify the physician and properly manage the resident's condition posed a substantial risk of serious harm.

A Construction Section Biennial Follow-Up survey was conducted to verify correction of previous deficiencies.

All deficiencies identified in the prior inspection have been corrected. No further action is required.

The Adult Care Licensure Section conducted a follow-up survey and complaint investigation initiated by the Craven County Department of Social Services on March 31, 2023, to assess compliance with health care regulations at Croatan Village.

The facility failed to ensure referral and follow-up for acute health care needs related to oxygen saturation notifications for Resident #2, failed to implement orders for obtaining a urinalysis for Resident #2, and failed to administer rapid-acting insulin as ordered for Resident #5. Non-compliance with medication administration continued despite abatement of a prior Type A1 violation.

Complaint investigation was initiated by the Craven County Department of Social Services on March 31, 2023, related to failure to notify PCP of abnormal oxygen saturations and failure to implement physician orders.

The Adult Care Licensure Section and the Craven County Department of Social Services conducted an annual survey, a follow-up survey, and complaint investigations from February 22, 2023 to February 24, 2023.

The facility failed to ensure exit doors were alarmed for residents with disorientation, maintain a hazard-free environment, ensure accurate and complete medication administration, update resident emergency contact information, provide adequate supervision to prevent elopement, serve therapeutic diets as ordered, treat residents with respect and dignity, and report incidents to the appropriate authorities.

The Adult Care Licensure Section conducted a follow-up survey and complaint investigations initiated by the Craven County Department of Social Services.

The facility failed to ensure complete and clarified medication orders for a resident, failed to provide personal care assistance related to incontinence, failed to implement certain physician orders including blood sugar and blood pressure checks, failed to keep a resident free from physical abuse, and failed to administer medications as ordered including insulin and other medications. Additionally, medication administration records were incomplete and residents were not always observed taking medications.

Complaint investigations were initiated by the Craven County Department of Social Services on November 23, 2022.

The Adult Care Licensure Section conducted a follow-up survey on August 23-24, 2022 to verify correction of previous deficiencies related to housekeeping, pest control, and medication administration.

The facility failed to maintain a hazard-free environment due to active mice in a resident room, failed to administer medications as ordered for multiple residents including pain and chronic condition medications, and failed to ensure medication aides observed residents taking their medications, leaving medications unattended. These failures were detrimental to resident health and safety.

The follow-up survey was triggered by a complaint of vermin infestation in the facility, specifically mice seen in resident rooms.

The Adult Care Licensure Section conducted an annual survey of Croatan Village on May 18-19, 2022 to assess compliance with state regulations for adult care homes.

The facility was found deficient in multiple areas including failure to provide non-disposable place settings in the Special Care Unit, lack of therapeutic diet menus, medication administration errors including improper insulin technique and incorrect medication dosages, incomplete medication administration records, and improper use and documentation of physical restraints.

The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies related to the facility's disaster and evacuation plan and tuberculosis testing compliance.

The facility failed to maintain an updated disaster and evacuation plan with annual documentation of submission and approval by the local emergency management agency, resulting in a Type A2 violation. Additionally, the facility failed to ensure two of five sampled residents received required second step tuberculosis testing upon admission.

The inspection was conducted in response to a complaint alleging that the facility had no water.

The complaint was found to be unsubstantiated; however, a deficiency was cited because the boiler providing domestic hot water broke down on 05/02/2019 and the building plumbing equipment was not maintained in a safe and operating condition.

Complaint alleged the facility had no water; complaint was unsubstantiated.

The Adult Care Licensure Section and the Craven County Department of Social Services conducted an annual and follow-up survey and complaint investigation on March 5-8, 2019.

The facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit at multiple fixtures, posing a risk of burns to residents. Additionally, the facility failed to ensure one resident received required two-step tuberculosis testing upon admission and failed to perform controlled substance screening for one staff member.

The survey included a complaint investigation conducted from March 5-8, 2019.

Biennial Follow Up Construction Survey conducted to verify correction of previously identified deficiencies related to building and physical plant compliance.

Some deficiencies were not corrected at the time of the survey. Issues included emergency release switches being inaccessible due to locked covers, a sagging exterior gate obstructing an emergency exit path, and fire rated doors held open with permanent magnets instead of being self-closing or automatic closing on fire alarm activation.

The facility was surveyed for conformance with applicable portions of the Minimum Standards and Regulations for Homes for the Aged and Adult Care Homes, as well as the North Carolina State Building Code, Institutional Occupancy, as part of a Biennial Construction Survey.

Multiple deficiencies were cited related to physical plant and safety, including failure to meet building code requirements for emergency release switches, exit door locks not operable by single hand motion, walls and ceilings not in good repair, hazards such as blocked electrical panels and unsecured oxygen tanks, inadequate fire safety rehearsals documentation, malfunctioning emergency lighting and exit signs, fire doors held open improperly, unsafe electrical equipment, portable electric heaters prohibited by code, hot water temperatures exceeding allowed limits, and lack of required exhaust ventilation in several areas.

The facility was surveyed for conformance with applicable portions of the Minimum Standards and Regulations for Homes for the Aged and Adult Care Homes of Seven or More Beds, as well as portions of the North Carolina State Building Code, Institutional Occupancy, as part of a Biennial Construction Survey.

Multiple deficiencies were cited including failure to maintain emergency illumination, inadequate ventilation in certain areas, unserviced HVAC grilles with particulate buildup, improper storage of oxygen cylinders, non-functional electrical ground-fault circuit interrupters, and failure to maintain smoke barrier doors and fire-rated doors in safe operating condition.

The facility was surveyed for conformance with applicable portions of the Minimum Standards and Regulations for Homes for the Aged and Adult Care Homes, as well as the North Carolina State Building Code, Institutional Occupancy, as part of a Biennial Construction Survey.

Multiple deficiencies were cited including failure to maintain emergency lighting, inadequate ventilation and exhaust in several areas, improper storage of oxygen cylinders, failure to maintain electrical ground-fault protection, and malfunctioning smoke barrier and fire-rated doors.