Navion of New Bern

The facility failed to ensure proper health care referral and follow-up for residents. Specifically, the facility did not complete a physical therapy referral for one resident and failed to send a fingerstick blood sugar reading log to a provider as requested for another resident.

The facility failed to ensure proper health care referral and follow-up for residents. Specifically, the facility did not schedule a physical therapy referral for one resident and failed to send a requested fingerstick blood sugar reading log to a provider for another resident.

The facility failed to ensure tuberculosis (TB) testing was completed for one resident upon admission. A review of the resident's records showed no documentation of TB testing or screening despite the requirement for testing prior to admission.

There was no documentation of tuberculosis (TB) testing or screening for Resident #3. The facility nurse and administrator were unaware that TB testing documentation was missing from the resident's record upon admission.

The facility failed to ensure referral and follow-up to meet the routine and acute health care needs of residents. Specifically, for two of five residents sampled, the facility failed to notify the primary care provider of a large red, swollen, and white bump on the left leg and failed to schedule a required follow-up appointment.

The facility failed to protect food and beverages from contamination by allowing items to be stored improperly. Specific issues included uncovered melted butter, undated food containers in cabinets and refrigerators, expired sour cream, and exposed or decaying food items in the pantry.

The facility failed to ensure that a resident assessment was completed within 10 days following a significant change in the resident's condition. This includes failures to update service plans when changes in activities of daily living, weight, or medical diagnoses occurred.

The facility failed to complete necessary risk assessments for all residents and did not consistently implement interventions for residents with increased needs for personal care and supervision. Documentation of these interventions in the resident record was also inconsistent.

The facility failed to ensure that residents with identified health care needs, such as podiatry or weight monitoring, were properly referred to appropriate providers. There was a lack of consistent documentation regarding communication between the community and healthcare providers.

The facility failed to maintain an adequate system for the documentation and implementation of new medical orders. There was a lack of a centralized clinical folder to ensure that physician orders, discharge orders, and consults were properly communicated to staff.

The facility failed to complete a resident assessment within 10 days following a significant change in condition for 2 of 2 residents sampled. Specifically, the facility did not conduct assessments for residents who experienced significant changes in their ability to walk and transfer.

The facility failed to complete a resident assessment within 10 days following a significant change in condition for 2 of 2 residents sampled. Specifically, the facility did not conduct assessments for residents who experienced significant changes in their ability to walk and transfer.