Spring Arbor of Greensboro

The facility failed to ensure that exit doors accessible to residents in the Special Care Unit (SCU) and the Locked Unit had a continuous sounding device that is activated when the door is opened. Specifically, one door in the SCU did not alarm when opened, and staff did not consistently respond to or deactivate the alarms on other exit doors.

The facility failed to ensure that 2 of 4 exit doors in the Special Care Unit and 2 of 2 doors in the Assisted Living Locked Unit had continuous sounding devices that were responded to and deactivated by staff.

A wound cleanser was left unattended on a bathroom sink in the Memory Care unit.

The FL-2 form for a resident was not updated.

The facility failed to obtain and document daily weights as ordered by the physician.

The facility failed to protect food from contamination, as evidenced by unlabeled or undated food, mold growth, expired food, and debris on floors, stoves, and storage bins.

The facility failed to ensure that mealtime table service in the Special Care Unit and the locked unit in Assisted Living included a complete place setting of a knife, fork, and spoon.

The facility failed to maintain a current listing of residents with physician-ordered therapeutic diets to guide food service operations.

The facility failed to ensure medications were administered according to physician orders for one resident. Specifically, insulin was administered despite blood sugar levels being below the required threshold (FSBS < 100) on multiple occasions in December 2022 and January 2023. This error resulted in a significant hypoglycemic event on 01/12/23 where the resident's blood sugar dropped to 38, requiring EMS intervention and hospitalization.

The facility failed to ensure medications were administered according to physician orders for one resident. Specifically, insulin was administered at 6:00 PM on multiple dates in December 2022 and January 2023 despite blood sugar levels being below the required threshold of 100 mg/dL, which should have triggered a hold on the medication.

The facility failed to provide supervision according to residents' needs and current symptoms for several residents. Specific failures included inadequate monitoring for residents exhibiting exit-seeking behaviors, elopement, and those at high risk for falls, as well as failure to address inappropriate physical contact between residents.

The facility failed to ensure that the rights of all residents are maintained and exercised without hindrance. This required staff re-education on timely communication of resident concerns to management and the importance of respecting resident dignity.

The facility failed to ensure every resident is free of mental and physical abuse, neglect, and exploitation. Staff required re-education to understand their responsibility in reporting concerns to management and providers to ensure a safe environment.

The facility failed to provide supervision in accordance with residents' assessed needs and care plans. Specifically, three residents were identified as lacking proper supervision, including instances of elopement, exit-seeking behaviors, multiple falls resulting in injuries, and inappropriate physical contact with other residents.

The facility failed to serve eight ounces of pasteurized milk to residents at least twice daily. During lunch and dinner observations in the locked unit, residents were served water, tea, or juice instead of milk. Additionally, milk was not provided to residents in a timely manner to assist with hydration during meal service.

The facility failed to serve eight ounces of pasteurized milk to residents at least twice daily. During meal observations on January 16, 2018, residents were served tea, water, or juice instead of milk, and staff did not consistently offer the required milk service during breakfast or lunch.