The Indigo at New Bern

The facility failed to ensure proper referral and follow-up to meet the acute health care needs of residents. Specifically, for one resident, the facility failed to obtain a STAT x-ray ordered by a provider and failed to document results for the ordered imaging. Additionally, the facility failed to notify a provider regarding blood sugar levels greater than 400 for another resident.

The facility failed to ensure referral and follow-up to meet the acute health care needs of residents. Specifically, the facility failed to obtain a STAT x-ray that was ordered for Resident #1 and failed to notify a provider regarding blood sugar levels greater than 400 for Resident #2.

The facility failed to ensure that the front entrance door, which had an alarm engaged for residents with dementia or wandering behaviors, was properly monitored. Specifically, the motion-activated front sliding door was found unlocked and lacked an audible sounding device to alert staff when opened.

The facility failed to ensure that the front entrance door was equipped with a continuously sounding alarm. For residents who are disoriented or exhibit wandering behavior, an audible device must be activated when the door is opened to the outside.

The facility failed to ensure that medication administration was in accordance with physician orders for one resident. Specifically, the facility administered insulin (Lantus and Humalog) using a sliding scale method that was inconsistent with the updated physician orders requiring scheduled dosing. Documentation errors were also noted, including failure to document the administration of Lantus on 04/07/25.

The facility failed to ensure that the preparation and administration of medications were in accordance with physician orders for 7 residents related to high blood sugar treatments. Specifically, for Resident #1, there were discrepancies between the physician's orders for sliding scale insulin and the actual administration instructions recorded in the facility's diabetic flow sheet.

The facility failed to notify a resident's physician of acute changes in status following a fall. Specifically, the resident experienced changes in behavior, appetite, and vision that were not communicated to the physician, despite the resident being on anticoagulants and having sustained a head injury during the fall.

The facility failed to notify a resident's physician of acute changes in health status for one resident. Specifically, the resident experienced changes in behavior, appetite, and vision following a fall, but the physician was not notified.