Arbor Springs Health And Rehab Center, LTD

Based on observations, interviews, and review of the facility's food contract company's policy, Bulk Food - Delivery and Usage, the facility failed to ensure food with an expired use by date was discarded, placing 114 of 117 residents in the facility at risk for foodborne illness if served. Findings include: The facility's contract food service company's undated policy Bulk Food - Delivery and Usage, revealed, .The bulk meals should be held at the proper temperature in the refrigerator and served to residents within 3 days of preparation. During an observation on 02/21/2022 from 9:45 AM to 9:58 AM, the following items prepared in another town by the food service contract company's central kitchen and stored on shelving in the walk-in cooler were observed: - Three large aluminum pans (full size steam table pans) containing chicken pot pie and labeled with a prepared date of 02/15/2022 and a use by date of 02/18/2022 - One small aluminum pan (1/2 size steam table pan) containing pureed chicken pot pie and labeled with a prepared date of 02/15/2022 and a use by date of 02/18/2022 - One…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews, and review of a facility policy titled, Catheter Care, the facility failed to ensure thorough cleaning of the penis during indwelling urinary catheter care for Resident Identifier (RI) #86, increasing the resident's risk for a urinary tract infection (UTI). The deficient practice affected RI #86, one of two residents sampled with an indwelling urinary catheter. Findings include: Review of a facility policy titled, Catheter Care, dated 06/01/2021, revealed: . Male: .15. Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). 16. With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis . RI #86 was most recently admitted to the facility on [DATE] and had diagnoses to include Retention of Urine and Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms. A review of RI #86's February 2022 Physician Orders, revealed an order dated 06/08/2021 directing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews,the facility failed to ensure: 1) Resident Identifier (RI) #223's oxygen was administered in accordance with the physician's order; and 2) RI #220's nebulizer mask and tubing was stored in a manner to prevent potential contamination when not in use. This deficient practice affected RI #223 and RI #220, two of four residents sampled for respiratory care. Findings include: 1) RI #223 was most recently admitted to the facility on [DATE]. RI #223's diagnoses list included the following: Acute and Chronic Respiratory Failure with Hypoxia (oxygen deficiency), Chronic Obstructive Pulmonary Disease (COPD), and Obstructive Sleep Apnea (OSA, temporary cessation of breathing during sleep). A review of RI #223's admission Minimum Data Set (MDS) dated [DATE] indicated RI #223 had no cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required extensive assistance of one person for their activities of daily living (ADLs).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and a review of the 2017 Food and Drug Administration Food Code, and facility policies related to Food Storage, the facility failed to: 1) completely air dry utensils, dishes and trays prior to storage and use; 2) consistently label food with preparation and use-by date (UBD) and discard food in a timely manner; 3) completely cover refrigerated food prior to storage; 4) ensure milk was stored in a manner to retain a recommended safe temperature of 41 degrees or less on the 6/4/19 lunch tray line; and hot food was maintained above 135 degrees F on the 06/05/19 tray line; 5) wash hands between dirty and clean tasks; and 6) maintain frozen food in a solid state during storage. These infractions had the potential to affect all 153 residents for whom meals were prepared and served at the time of this survey. Findings Included: 1) AIR DRYING The 2017 Food Code mandates under 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT AND UTENSILS: (A) Shall be air-dried . (B) May not be cloth dried . On 06/04/19 at 11:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and a review of the 2017 Food Code, the facility failed to ensure the Hot Box consistently maintained temperatures above 135 degrees Fahrenheit (F) for the storage of foods to be served from the 06/05/19 supper meal. This had the potential to affect all 153 residents who received special food requests (such as sweet potato fries, fried fish, grilled cheese sandwiches) or planned (replacement) food added to the line as needed. Findings Included: The 2017 Food and Drug Administration Food Code, regulation #3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding specifies under (A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 135 degrees F or above . During the 06/05/19 supper tray line at 5:05 PM, the heated reach in Hot Box at the start of the tray line displayed a temperature of 98 degrees, which soon thereafter, dropped to 95 degrees. The Surveyor asked the Certified Dietary Manager (Employee Identifier/EI) #2 what food items were stored inside. EI #2 explained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and review of a facility policy titled, Enteral Tube Feeding via Continuous Pump, with a revised date on March 2015, the facility failed to ensure licensed staff applied a label, with required information, onto Resident Identifier (RI) #110 and RI #351's tube feeding bottles. This affected two of three residents observed for tube feedings on one of three days of the survey. Findings include: Review of a facility policy titled Enteral Tube Feeding via Continuous Pump, revised 3/2015, revealed the following: . Initiate Feeding . 5. On the formula label document initials, date, time the formula was hung/administered, and initial that the label was checked against the order . 1. RI #110 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included Dysphagia and gastrostomy status. On 6/4/19 at 4:20 PM, the surveyor observered a Glucerna 1.2 Cal bottle hanging and connected to RI #110. There was no label noted on the bottle. 2. RI #351 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure RL(Room Locator) #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12, did not have a toilet with exposed rusty bolts. This affected resident bathrooms on 4 of 9 halls of the facility. Findings include: On 06/04/2019, during the initial tour of the facility, the following was observed in resident bathrooms. RL 1 had a missing bolt cover on the left side rusted appearance uncapped. RL 2 had a missing bolt cover on the left and right side with rusted appearance uncapped. RL 3 had a rusted toilet bowl bolt with no caps on the right and left side. RL 4 had no toilet bowl bolt cover on right and left side. RL 5 had rusted toilet bowl bolts uncapped on the right and left side. RL 6 had rusted toilet bowl bolts with uncapped on the right and left side RL 7 had rusted toilet bowl bolts uncapped. RL 8 had rusted toilet bowl bolts that were uncapped. RL 9 had missing cover on right side and the bolt was rusty in appearance on the toilet. RL 10 had a missing cover on the right side of the toilet bolt that was rusty. RL 11 had a missing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, medical record review, and a review of the facility's policies titled, Personal Protective Equipment - Gloves and Handwashing / Hand Hygiene, the facility failed to ensure nursing staff wash their hands: 1. after removing gloves; 2. before leaving the resident's room; 3. after cleaning stool from a resident's buttocks, and 4. touching clean items, such as a new container of perineal wipes and a clean brief, while providing incontinence care to Resident Identifier #137. This affect one of three observations of incontinence care. Findings Include: A review of the facility's policy titled, Personal Protective Equipment - Gloves, with a revised date of July 2009, revealed: Policy Statement Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Policy Interpretation and Implementation . 8. Wash your hands after removing gloves. A review of the facility's policy titled, Handwashing/Hand Hygiene, with a revised date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and review of a facility policy titled Main Dining Room Meal Service Assistance, the facility failed to ensure Resident Identifier (RI) #84 did not have to wait for his/her supper meal on 6/19/18 while other residents at the tables were already dining. This affected one resident, seated at one of 12 tables, in the main dining room for the supper meal on 6/19/18. Findings include: A review of the facility policy titled Main Dining Room Meal Service Assistance, implemented 4/3/2017, revealed: . 4. Meal observation will reflect: 1. Meals provided to all residents at a table at the same time. On 6/19/18 at 5:00 PM, RI # 84 was observed sitting at a table with four other residents in the main dining room. RI # 84 received his/her supper tray 25 minutes after the other residents at the table had received their trays. RI #84 was observed to ask the dietitian about his/her tray. RI #84's tray was pulled from the food cart 25 minutes after the other residents at the table had received their trays and were almost finished eating their meals. On 6/19/18 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy titled Use of Side Rails, the facility failed to ensure an individualized plan of care that addressed the use of top 1/4 (quarter) side rails was developed for Resident Identifier (RI) #66. The facility further failed to ensure a urinary catheter care plan was developed for RI #89. This affected two of 32 sampled residents whose care plans were reviewed. Findings include: 1) Review of an undated policy titled Use of Side Rails revealed the following: Policy: The facility must ensure that residents receive treatment and care in accordance with . the comprehensive person-centered care plan . Policy statement: .5. The resident's specific use of side rails will be addressed in the residents' care plan. RI #66 was admitted to the facility on [DATE] with diagnoses of Dementia and a history of Femur Fracture. Review of RI #66's care plan for ADL (Activity of Daily Living) assistance/self care deficit related to dementia with a problem onset of 4/13/18…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of the facility's policies titled . Infection Control and Standard Precautions, the facility failed to ensure Resident Identifier (RI) #31's catheter tubing and bag were not directly on the floor. Further, the facility failed to ensure Certified Nursing Assistants (CNAs) removed their gloves and washed their hands after providing catheter care to RI #76, before touching the tube feeding pump, placing a clean pad under the resident, and touching the resident's body. This affected two of four residents sampled for catheters. Findings include: A review of a facility policy titled . Infection Control, with a revised date of August 2007, revealed: . Policy Statement This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary . environment . to help prevent and manage transmission of diseases and infections. 1) RI #31 was readmitted to the facility on [DATE] with a diagnosis of Urinary Retention. RI #31's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.