Comer Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility policy titled, Medication Storage in the Care Center, the facility failed to label and date an opened multidose medication vial, leaving no way for staff to determine its beyond-use date for one of one Medication Storage Rooms observed. This deficient practice could have caused the administration of expired or contaminated medication, placing 67 residents at risk for infection, reduced medication effectiveness and incorrect administration of medication.Findings include:A review of the Facility's Pharmacy Services Policy titled Medication Storage In the Care Center dated [DATE] showed under Intent: To facilitate safe, secure, and proper storage of medications and biologicals following manufacturer's recommendations or those of the supplier. The Policy further states under Guideline: . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or otherwise compromised are promptly removed from stock,…

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 record review and staff interviews, the facility failed to provide appropriate infection control surveillance and to execute an organized and effective infection control prevention program to include surveillance monitoring. The deficient practice posed the potential for all 67 facility residents to be at increased risk for infection and medication ineffectiveness.Findings include:Review of the Infection Prevention Surveillance Binder for fiscal years 2025 and 2026 revealed surveillance monitoring reports titled HAI (Health Impact Assessment) Summary Reports were incomplete for 12 of 12 months reviewed. There was no analysis for specific trends or documented actions taken. There was no HAI Summary report for October 2025. The tab for October had a blank page and did not list any statistics for the month, infection analysis rates nor actions taken. There also were no HAI reports for August 2025, January 2026 nor February 2026. Interview on 02/26/2026 at 1:13 PM with the Infection Preventionist (IP), who is also the Assistant Director of Nursing (ADON), and two Surveyors…

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, staff interview, and review of facility policy titled Menus, the facility failed to properly prepare foods to conserve nutritive value during the preparation of puree food for nine residents who received a puree diet. The deficient practice had the potential to place nine of nine residents who received a pureed diet at risk of decreased nutritional intake. Findings include: Review of the facility policy titled Menus, review date 12/29/2023, revealed, Menu items should be nutritionally adequate, attractively served, palatable, at a safe and appetizing temperature, and within cost or budget projections. Observation and interview on 1/15/2025 at 10:16 am with Dietary [NAME] EE revealed he was preparing pureed carrots for nine residents. Dietary [NAME] EE added water and thickener to the puree machine along with the carrots and blended until he stated it was the correct consistency. Dietary [NAME] EE revealed that he did not use vegetable broth when preparing puree and wasn't sure if they had any vegetable broth. A review of the recipe for Carrots Herb Pureed Thick…

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, staff interviews, record review, and review of the facility's policy titled Patient's Plan of Care, the facility failed to implement care plans for two of 20 sampled residents (R) (R42 and R2). Specifically, the facility failed to provide proper supervision for R42 and to assist with hearing aid placement for (R2). This deficient practice had the potential to affect the residents' health and safety. Findings include: A review of the facility's policy titled, Patients Plan of Care dated 12/29/2023 under section titled Guideline revealed, Each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patients' medical, physical, mental and psychological needs. 1. Review of the Electronic Medical Record (EMR) revealed R42 was admitted to the facility with diagnoses that included but not limited to Alzheimer's/Dementia, Traumatic Brain Injury (TBI), and history of pedestrian on foot injured in collision…

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, resident and staff interviews, record review, and review of the facility's policies titled Patient Plan of Care and Care of Hearing Aids, the facility failed to assist one out of four sampled residents (R) (R2) with the use of hearing aids. Specifically, the facility failed to assist with the proper use of hearing aids by not placing them in and removing them. This failure to provide the necessary support could result in communication barriers. Findings include: A review of the facility's policy titled, Care of Hearing Aide dated 12/29/2023 under section titled Intent revealed, The primary intent of caring for a hearing aid is to maintain the patients hearing aid in good order. A review of the Electronic Health Record (EHR) for R2 revealed, she was admitted to the facility with diagnoses that included but not limited to, need for assistance with personal care, unspecified dementia with mood disturbance, chronic systolic (congestive) heart failure, chronic respiratory failure with hypoxia,…

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, staff interviews, and review of the facility's policy titled Skilled Nursing Services - Elopement, the facility failed to closely monitor one of 13 residents (R) R42 for elopement potential. This deficient practice had the potential to place residents at risk for safety concerns including but not limited to physical and/or mental distress. Findings include: Review of the policy titled Skilled Nursing Services - Elopement dated 12/29/2023 revealed, the intent is to promote person-centered care for patients at risk for elopement. Guideline documented the center implements mechanisms and procedures for monitoring and managing patients at risk for elopement to minimize the risk of a patient leaving a safe area without authorization and/or appropriate supervision. Procedure revealed the center will take a proactive approach for new patients and assess new admissions for elopement risk. The licensed nurse will re-assess patient at least quarterly, annually, with any significant…

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, staff interviews and review of facility's policy titled, Infection Prevention Plan, the facility failed to prevent the spread of infections by not properly securing and storing clean linen in one out of three halls (Hall A). This deficient practice had the potential to cause the spread of infection throughout the facility. The facility census was 76 residents. Findings include: Review of facility's policy titled Infection Prevention Plan dated 12/29/2023 under section titled Goals revealed, The goals of the infection prevention program are as follows: To prevent and control the transmission of infectious and communicable diseases; To prevent healthcare associated infections . Under the section titled Scope revealed, The center provides services on an in-patient basis to a geriatric population with various medical conditions, including hospice, hemodialysis and other special needs .Implementation of Preventive Measures: Prevention of a spread of infections is accomplished by use of standard precautions and other barriers. An observation and interview conducted…

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, interviews, and review of the policy titled 'Restraints', the facility failed to ensure three residents (R) (R#36, R#64 and R#65) were free from the use of physical restraints. The sample size was 26. Findings include: Review of the undated policy titled 'Restraints' revealed under procedural guidelines- Prior to use of a restraint, the following should be completed: 1. Patient's need for restraint assessed. 2. Restraint Consent. This includes the patient and/or responsible party consent, as well as reason for restraint and type of device. 3. Physician order for device (to include type of device, and when it may be used).' 1. Review of the electronic medical record (EMR) revealed that R#36 was admitted to the facility on [DATE] with diagnoses including but not limited to Huntington's disease, dementia, dysphagia, and aphasia. Review of Significant Change Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognitive Patterns resident is rarely/never understood and has both short and…

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, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for two residents (R), (R#36 and R#65) of 23 sampled residents. Findings Include: 1. R#36 was admitted to the facility on [DATE] with diagnoses including but not limited to Huntington's disease, dementia, dysphagia, and aphasia. Review of Significant Change Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognitive Patterns resident is rarely/never understood and has both short and long-term memory problems. Section G-Functional Abilities revealed R#36 is dependent on one-person physical assistance with activities of daily living (ADLs). Section P-Restraints revealed R#36 does not use physical restraints. Observation on 9/27/22 at 11:48 a.m. revealed R#36 lying in bed with full size bedrails in the up position on both sides of bed. Observation on 9/28/22 at 9:46 a.m. revealed R#36 in bed with full size bedrails in the up position. Observation on 9/29/22 9:33 a.m. revealed R#36 lying…

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, interviews and review of the facility policy titled Skilled Inpatient Services Patient's Plan of Care dated 12/4/21, the facility failed to evaluate and revise the care plan interventions and/or determine the need to identify additional interventions for fall prevention for one resident (R) (#64) who had been assessed to be at risk for falls and who sustained additional falls. The sample size was 26 residents. Findings include: Review of the facility policy titled Skilled Inpatient Services Patient's Plan of Care with a revision date of 12/4/21 reads: The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive car plan should also be updated as ongoing clinical assessments identify changes. Review of the clinical record for R#64 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to orthostatic hypotension,…

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 and interviews, the facility failed to obtain a Physician order for use of full size bedrails for one resident (R)#36. The sample size was 26. Findings include: Review of the electronic medical record (EMR) revealed that the facility admitted R#36 on 5/3/13. He was admitted with multiple diagnosis that included, but was not limited to Huntington's disease, dementia, dysphagia, and aphasia. Review of R#36's Significant Change Minimum Data Set (MDS) dated [DATE], revealed the R#36 is rarely/never understood and has both short and long-term memory problems. He is dependent on one-person physical assistance with activities of daily living (ADLs). The MDS also revealed that R#36 does not use physical restraints. Observation on 9/27/22 at 11:48 a.m. revealed R#36 was in bed. Both sides of the bed had full size bedrails in the up position. Observation on 9/28/22 at 9:46 a.m. revealed R#36 was in bed. The full size bedrails in the up position on both sides of the bed. Observation on 9/29/22 9:33…

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.