Arbor Oaks Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Arbor Oaks Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 27, 2024

  Based 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. The findings are: 1. […]

• No harm, potential for more than minimal, widespreadF812Jun 27, 2024

  Based 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… […]

• No harm, potential for more than minimal, widespreadF812Jul 28, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Jul 27, 2021

  Based on observation, record review and interview, the facility failed to ensure infection prevention and control practices were implemented for the prevention and transmission of possible Covid-19 and other communicable diseases and infections by ensuring staff wore face masks to cover the mouth and nose. This failed practice had the potential to affect 66 residents who resided in the facility according to the Resident Census List provided by the Administrator on 7/25/21. The findings are: 1. On 7/25/21 at 11:42 a.m., Certified Nursing Assistant (CNA) #1 was seen through the window of the front entrance door walking from the East Hall to the West Hall without any facial covering on. 2. […]

• No harm, potential for more than minimal, patternF812Jul 2, 2025

  Based 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. The findings include: On 06/29/25 at 10:15 AM, during an observation, an opened bag of bread was on a rack on top of the food preparation counter, exposing it to air. […]