Spring Arbor of Kinston

The facility failed to provide proper table service for residents, specifically lacking necessary non-disposable place settings. Required items such as napkins, knives, forks, spoons, plates, and beverage containers were not consistently available during meals.

The facility failed to ensure medications were administered within scheduled times and lacked proper follow-through on new order processes. Additionally, there were deficiencies in Med Tech training regarding medication cart audits, shift-to-shift reports, and EHR documentation.

The facility failed to timely notify the County Department of Social Services (DSS) regarding resident incidents. Specifically, the Executive Director failed to email the required incident report to County DSS following a resident incident.

The facility failed to ensure one of five sampled residents was tested for tuberculosis disease upon admission in compliance with required control measures. Specifically, a resident's two-step testing record showed an undocumented first skin test and a second step consisting of a chest x-ray that did not mention tuberculosis. The Resident Care Coordinator was unaware that a chest x-ray could be used as the second step for TB screening.

The facility failed to ensure medications were administered as ordered for one resident during the 8:00am medication pass. Specifically, medications that were not recommended to be crushed, such as Aspirin EC, Metoprolol Succinate ER, and Potassium Chloride ER, were improperly handled despite orders to provide medications in pudding or applesauce.

The facility failed to notify the primary care provider (PCP) regarding changes in condition and clinical parameters for 2 of 5 sampled residents. Specifically, the facility did not notify the PCP for finger stick blood sugars and blood pressures that were outside of ordered parameters, nor for a resident who required a follow-up appointment after a fall.

The facility failed to notify primary care providers regarding changes in resident condition and clinical parameters. Specifically, physicians were not notified of finger stick blood sugars and blood pressures that were outside of ordered parameters, nor were they notified of a resident's injury from a fall requiring follow-up.

The facility failed to ensure residents received care and services that are adequate, appropriate, and in compliance with physician orders and state regulations. This was evidenced by the failure to follow clinical protocols regarding physician notification for changes in resident status.

The facility failed to notify the primary care provider (PCP) regarding changes in condition and clinical parameters for 2 of 5 sampled residents. Specifically, the facility did not notify the PCP for finger stick blood sugars and blood pressures that were outside of ordered parameters, nor for a resident who required a follow-up appointment after an injury from a fall.

The facility failed to provide supervision in accordance with a resident's assessed needs, as evidenced by one resident sustaining seven unwitnessed falls between January and March 2022. Specifically, the resident's care plan lacked documented fall interventions, and the required 'rose card' for high-risk residents was not present in the room.