Navion of Goldsboro

The facility failed to ensure proper referral and follow-up to meet the healthcare needs of a resident. Specifically, the facility failed to notify the provider as ordered on two occasions following elevated blood glucose readings.

The facility failed to ensure medications were administered as ordered, resulting in a 9% medication error rate. Specifically, during the 8:00am medication pass on 04/05/23, Coreg 3.125mg was not administered to Resident #6 despite being documented as given on the eMAR.

The facility failed to ensure medications were administered as ordered for 2 of 4 residents observed during a medication pass. Specifically, a resident did not receive a prescribed dose of Coreg for hypertension, and a resident received Donepezil during the morning pass despite it being ordered for the evening.

The facility failed to ensure the medication administration record (MAR) was accurate for two residents. Specifically, insulin was documented as administered when blood sugar levels were below the required parameters, and Xanax administration was not properly reconciled with controlled substance count sheets.

The facility failed to ensure the medication administration record (MAR) was accurate for 2 of 3 sampled residents. Specifically, for Resident #1, insulin was documented as administered on multiple occasions even when blood sugar levels were below the required parameters for administration.