Arbor Oaks Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure foods stored in the freezer, refrigerator, and dry storage area were covered; one of two ice scoop holders were maintained in a sanitary manner, expired food items were promptly removed and discarded on or before the expiration or use by date; and that dietary staff washed their hands between dirty and clean tasks and before handling clean equipment for two of two meals observed.

Inspectors wroteBased on interview and record review the facility failed to convey a resident's personal funds to the individual or representative administering the individual's estate within 30 days for two (Resident #212 and Resident #213) of three residents reviewed for whom the facility maintained trust accounts.

Inspectors wroteBased on observation and interview, the facility failed to post and make readily accessible to residents and visitors, the daily nurse staffing log in a clear and readable format to include the facility name, date, total census, total number, and actual hours worked by nursing staff.

Inspectors wroteBased on record review, interview and facility policy review the facility failed to report an allegation of sexual abuse to the State Survey Agency within the required 2-hour time period for one (Resident #2) of three sampled residents reviewed for abuse.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff followed care planned intervention requiring two staff members to perform mechanical lift transfers to promote resident safety and prevent fall with injury for 1 (Resident #15) of 8 (Residents #3, #6, #10, #15, #20, #26, #33 and #46) sampled residents who required the mechanical lift for transfer. This failed practice resulted in actual harm for Resident #15, who fell and sustained a fracture, and had the potential to cause more than minimal harm for 13 residents who required transfers with a mechanical lift. The facility failed to ensure that chemicals were kept out of reach for 1 (Resident #49) sampled resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food items stored in the freezer were sealed or covered, food items stored in the storage room were stored in accordance with the manufacturer's instructions; failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean dishes or food items; expired products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria, failed to ensure hot foods was maintained at or above 135 degrees Fahrenheit (F.) while awaiting to be served to prevent potential food borne illness, and failed to ensure leftover food items were not used for residents who received meals from 1 of 1 kitchen to maintain food quality and prevent the growth of bacteria. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who required extensive assistance with personal hygiene were regularly offered trimming or shaving of facial hair to maintain good grooming and hygiene for 3 (Resident #23, #49, and #53) of 3 sampled residents reviewed for activities of daily living (ADLs), and the facility failed to provide continent care every 2 hours for 1 (Resident #53) reviewed for continent care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of residents for 1 of 1 meal observed. This failed practice had the potential to affect 36 residents who received regular diets, 23 mechanical soft diets, and 2 residents who received pureed diets from 1 of 1 kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 2 residents who received pureed diets.

Inspectors wroteBased on observation, record review and interview, the facility failed to report to the State Survey Agency a fall from the mechanical lift that resulted in major injury for 1 (Resident #15) sampled resident that occurred when a staff member failed to follow care planned intervention requiring two people for lift transfers.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure freezer temperature was maintained at 0 degrees Fahrenheit or below and all foods were frozen solid to prevent the potential for food bore illness; foods stored in the freezer were sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 30 residents who received meals from the kitchen (total census: 57) as documented on a list provided by Dietary Supervisor.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nail care was regularly provided to maintain good hygiene and prevent potential injuries or infections for 3 (Residents #13, #30 and #43) of 15 (Residents #2, #4, #8, #9, #13, #18, #30, #31, #36, #37, #38, #43, #44, #49 and #50) sampled residents who required assistance with nail care. This failed practice had the potential to affect 24 residents on the [NAME] Unit who were dependent for nail care as documented on a list provided by the Director of Nursing (DON) on 07/26/23 at 11:31 AM.

Inspectors wroteBased on observation of the Medication Pass, record review, and interview, the facility failed to ensure medications were removed from the top of the medication cart and the cart was locked when outside of the nurse's line of sight, to prevent the potential for accidents. This failed practice had the potential to affect 10 residents who received medications from the East Hall medication cart as documented on a list provided by the Administrator on 07/26/23 at 9:22 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure oxygen was administered at the prescribed rate for 2 (Residents #9 and #43) sampled residents and failed to follow the resident preference for no humidifier bottle for 1 (Resident #43) of 4 (Residents #8, #9, #18, #43) sampled residents who had a Physician's Order for oxygen. This failed practice had the potential to affect 11 residents who had a Physicians Orders for oxygen as documented on a list provided by the Administrator on 07/26/23 at 7:44 AM.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure unauthorized personnel were monitored by a licensed nurse when in 1 (Nurses Station) of 2 (Nurses Station and Light House Unit) Medication Rooms.

Inspectors wroteBased on observation, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets, and food was prepared appropriately to meet the needs of the residents to conserve nutritive value, flavor, and encourage adequate nutritional intake for 1 of 1 meal observed. This failed practice had the ability to affect 5 residents who have a Physician's Order for a pureed diet according to a list provided by the Dietary Supervisor on 07/27/23 at 11:41 AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure the call light system was maintained in proper working order to assure residents could call for assistance when needed for 2 (Residents #23 and #51) of 6 (Residents #23, #38, #49, #50, #51 and #259) sampled residents who resided on the Light House Unit.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident assessment accurately reflected a level II Preadmission Screening and Resident Review (PASARR) evaluation for 1 (Resident #36) of 4 (Residents #30, #36, #38 and #43) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and the PASARR evaluation report into a resident's Care Plan to facilitate needed care for 1 (Resident #36) of 4 (Residents #30, #36, #38 and #43) sampled residents.