Arbor Lake Health and Rehab

In the surveyor’s words

From the most serious findings on record at Arbor Lake Health and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF803Aug 9, 2023

  Based on observation, interview, the facility's policies for Menu Planning and Accuracy and Quality of Tray Line Service, the facility's 2023 Spring/Summer Menu, Week 3, Tuesday, and the facility's posted alternate menu for supper Week 3, Tuesday; the facility failed to provide Oatmeal in 6-ounce portions at breakfast and Country Fried Steak in 3-ounce portions at supper on Tuesday, August 8, 2023. This had the potential to affect 74 of 74 residents receiving meals from the kitchen. […]

• No harm, potential for more than minimal, widespreadF812Aug 9, 2023

  Based on observation, interview, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, the facility's policies for Cleaning and Sanitation of Dining and Food Service Areas, Cleaning Dishes/Dish Machine, Dish Machine Temperature Log, Food Storage, Use and Storage of Food Brought in by Family or Visitors, and Cleaning Instructions: Food Carts, the Dishwasher Temperature/Chemical Record for August 2023, the Sanitizing Sink Temperature/Chemical Record for August 2023, and the posted Cleaning Assignments; the facility failed to ensure the kitchen and storage room floors were clean, kitchen equipment was clean, food safety logs were accurate, food and paper products were properly stored, interior of drawers were not rusted, and leftovers were labeled with Use-By dates so as… […]

• No harm, potential for more than minimal, isolatedF584Aug 9, 2023

  Based on observations, interviews and review of a facility policy Shower Cleaning Policy, the facility failed to ensure the shower in Resident Identifier (RI) #20's room was free of orange/yellow and brown discoloring in the shower and on the shower curtain. This was observed on 8/6/23 and again on 8/8/23. This affected one of one resident shower room. Findings Include: A review of facility policy Shower Cleaning Policy dated 8/9/23 revealed, 1. Showers are cleaned and disinfected daily. 3. Spray Broad-Cide 128 onto shower walls, shower curtains and shower floors. RI #20 was admitted to the facility 12/23/21. A review of RI #20's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date of 05/18/2023 revealed RI #20 was independent for bathing and walking. […]

• No harm, potential for more than minimal, isolatedF755Aug 9, 2023

  Based on interview, record review and review of a facility policy titled Destruction of Unused Drugs, the facility failed to ensure the Non-Controlled Medication Destruction Sheets contained the two required signatures. This affected two of eight months ([DATE] and [DATE]) of Non-Controlled Medication Destruction Sheets reviewed. Findings Include: A facility policy titled Destruction of Unused Drugs, with a revised date of [DATE], revealed the following: Policy: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations. Policy Explanation and Compliance Guidelines: . 4. The actual destruction of drugs conducted by our facility must be witnessed by the consultant pharmacist and one of the following individuals: a. […]

• No harm, potential for minimal, widespreadF550Aug 9, 2023

  Based on observation, interview, the facility's policies for The Person Centered Dining Approach, Dining and Meal Service, and Dining Room Service, and the facility's Resident Rights; the facility failed to ensure disposable Styrofoam cups were not used for serving coffee at breakfast on Tuesday, August 8, 2023, although re-usable insulated coffee mugs were available. This had the potential to affect 74 of 74 residents receiving meals from the kitchen. Findings Include: The facility's policy for The Person Centered Dining Approach, undated, included the following: Policy: Person centered care allows individuals to live as normal a life as possible. […]