Inspection Reports for
Arbor Lake Health & Rehab, LLC
1365 Gatewood Drive, Auburn, AL, 36830
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Census: 74
Deficiencies: 5
Date: Aug 9, 2023
Visit Reason
Routine inspection conducted to assess compliance with regulatory standards related to resident rights, safety, dietary services, medication destruction, food safety, and facility cleanliness.
Findings
The facility was found deficient in multiple areas including use of disposable Styrofoam cups instead of reusable coffee mugs, unclean showers with mold and mildew, incomplete signatures on medication destruction sheets, improper portion sizes in meals, and multiple food safety and sanitation violations in the kitchen and storage areas. These deficiencies had the potential to affect many residents.
Deficiencies (5)
Use of disposable Styrofoam cups for serving coffee instead of reusable insulated coffee mugs.
Shower in resident's room had orange/yellow and brown discoloring, mold and mildew on shower curtain and surfaces.
Non-Controlled Medication Destruction Sheets lacked the two required signatures for two of eight months reviewed.
Facility failed to provide proper portion sizes of oatmeal (served 4 oz instead of 6 oz) and Country Fried Steak (served less than 3 oz) as per menu.
Kitchen and storage room floors were dirty; kitchen equipment had residue and grease build-up; food safety logs were incomplete or inaccurate; food and paper products were improperly stored on the floor; leftover foods were not labeled with correct Use-By dates; drawers were rusted and greasy; serving carts were dirty with food particles and debris.
Report Facts
Residents affected: 74
Insulated coffee mugs found: 19
Medication destruction sheets reviewed: 8
Portion size oatmeal: 6
Portion size oatmeal served: 4
Portion size Country Fried Steak: 3
Portion size Country Fried Steak observed: 2.25
Portions per box: 71
Dishwashing machine chlorine concentration: 50
Boxes of Canola oil: 2
Foam cups box: 1
Blue insulated mugs: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding coffee cup usage and medication destruction sheet signatures. | |
| Dietary Manager | Interviewed regarding coffee cup usage, meal portion sizes, food safety, and kitchen cleanliness. | |
| Registered Dietitian | Interviewed regarding meal portion sizes and dining experience. | |
| Certified Nursing Assistant (CNA)/Supply Clerk | Observed serving coffee in Styrofoam cups and interviewed about coffee cup availability. | |
| Maintenance Director | Interviewed regarding mold in resident shower. | |
| Housekeeping Supervisor | Interviewed regarding shower cleanliness and mold/mildew observations. | |
| PM Dietary Aide | Observed washing dishes and recording dishwashing machine data. | |
| AM Cook | Observed meal preparation and interviewed about serving sizes and cleaning duties. | |
| PM Cook | Observed meal portion sizes and food packaging. | |
| District Manager for contract food service | Observed meal portion sizes and advised on protein serving requirements. |
Inspection Report
Routine
Census: 74
Deficiencies: 5
Date: Aug 9, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory standards related to resident rights, safety, dietary services, medication destruction, food safety, and facility cleanliness.
Findings
The facility was found deficient in multiple areas including failure to provide reusable coffee cups, inadequate cleaning of resident showers, incomplete medication destruction documentation, improper portion sizes in meals, and multiple food safety and sanitation issues in the kitchen and food storage areas. These deficiencies had the potential to affect many residents.
Deficiencies (5)
Failure to ensure disposable Styrofoam cups were not used for serving coffee at breakfast despite availability of reusable insulated coffee mugs.
Failure to ensure the shower in a resident's room was free of mold and discoloration, indicating inadequate cleaning.
Non-Controlled Medication Destruction Sheets lacked the two required signatures for several months.
Failure to provide proper portion sizes of oatmeal at breakfast and Country Fried Steak at supper as per menu specifications.
Failure to maintain kitchen and storage room floors clean, kitchen equipment clean, accurate food safety logs, proper food and paper product storage, and labeling of leftovers with Use-By dates to prevent cross contamination and ensure food safety.
Report Facts
Residents affected: 74
Insulated coffee mugs found: 19
Medication destruction months affected: 2
Oatmeal portion size served: 4
Country Fried Steak portion size: 2.25
Dishwashing machine chlorine concentration: 50
Food storage height requirement: 6
Safe refrigerator temperature range: 36-46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding coffee cup usage and medication destruction sheet signatures | |
| Dietary Manager | Interviewed regarding coffee cup availability, meal portion sizes, kitchen cleanliness, and food safety logs | |
| Registered Dietitian | Interviewed regarding coffee cup observation and meal portion size concerns | |
| Certified Nursing Assistant (CNA)/Supply Clerk | Observed serving coffee in Styrofoam cups and interviewed about coffee cup usage | |
| Maintenance Director | Interviewed regarding mold in resident shower | |
| Housekeeping Supervisor | Interviewed regarding mold and mildew in resident shower | |
| PM Dietary Aide | Observed washing dishes and recording dishwashing machine data | |
| AM Cook | Observed and interviewed regarding meal preparation and cleaning duties | |
| PM Cook | Observed portion size of Country Fried Steak | |
| District Manager for contract food service | Observed and commented on meal portion sizes |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 29, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Arbor Lake Health and Rehab.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 4
Date: Jul 25, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to discharge procedures and infection prevention and control practices at Arbor Lake Health and Rehab.
Findings
The facility failed to ensure a discharge summary was completed for one resident discharged on 05/02/2019. Additionally, infection control deficiencies were identified including improper glove use by nursing staff during medication and tube feeding administration, bare hand contact with resident food by a CNA, and failure to wash hands between glove changes during pericare.
Deficiencies (4)
Failure to ensure a discharge summary was completed for Resident Identifier #84 at time of discharge.
Medication nurse moved floor mat with gloves on then administered tube feeding and medications without changing gloves, risking contamination.
Certified Nursing Assistant touched resident's bun with bare hands while serving meal, risking cross contamination.
Certified Nursing Assistant did not wash hands between glove changes during pericare, risking contamination.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding discharge summary for Resident Identifier #84 | |
| Licensed Practical Nurse | Observed and interviewed regarding improper glove use during medication and tube feeding for Resident Identifier #7 | |
| Certified Nursing Assistant | Observed and interviewed regarding bare hand contact with resident food and pericare hand hygiene for Resident Identifier #60 | |
| Registered Nurse, Infection Control Nurse | Interviewed regarding infection control practices and glove use |
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