Bolingreen Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, and a review of the facility's records, and policy titled Storage Area, the facility failed to discard expired food items and failed to properly label and date. Additionally, the facility failed to maintain sanitary practice during food-handling and hand hygiene. The deficient practices had the potential to place 69 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of facility document titled Ready 365 Best Practice, dated 04/2024, revealed in the subject Hand Washing documented When to wash hands, Handling raw meat, poult y, and seafood (before and after), Leaving and returning to the kitchen/prep area, Taking out garbage. How to wash hands Total Process: 20 seconds Wet hands and arms. Use running warm water. Apply soap. Make sure there is enough soap to build a good lather. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to date, label, and/or cover bread products stored in the kitchen, and failed to keep the kitchen's two ovens, large manual can opener and its table base attachment, and food preparation pans clean. The facility also failed to discard two opened containers of thickened beverages stored in resident refrigeration for greater than seven days. This failure had the potential to create an environment for food-borne illnesses, which could affect 80 of 80 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to maintain a clean environment by storing unwashed and unsanitized mattresses next to racks of clean resident clothing in the shared clean laundry room and central supply room. This failure had the potential for residents being subject to the spread of infections within a facility, leading to more serious illnesses.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure the laundry dryers were maintained to ensure safe operating conditions. This failure placed the facility at an increased risk of fire and had the potential to affect all residents who resided at the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure over the counter (OTC) medications were securely stored. This failure had the potential for unauthorized people to access the medication.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide a therapeutic diet as ordered for one resident (Resident (R) 59) of six residents reviewed for nutrition and/or food out of a total sample of 22 residents. This failure created a potential choking or swallowing hazard for R59, who had a diagnosis of dysphagia (difficulty with swallowing).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure one Resident (R)180, with pressure ulcers, received treatment and services to promote healing. Actual harm was identified when a statin (STAT) lab order on 11/5/2023 was not followed up on by staff, and twelve days later, on 11/17/2023, R180 was admitted to the hospital with sepsis due to a wound infection.

Inspectors wroteBased on observation, record review, interview, and review of facility policy Pain Assessment, the facility failed to stop and address verbal and facial expressions of pain during wound care for one resident (R) (R286) observed for wound care. Actual harm was identified on 2/2/2024 when Registered Nurse (RN) AA failed to assess and administer pain medication to R286 prior to providing wound care treatment, which resulted in pain during the treatment.

Inspectors wroteBased on observations, interviews, and review of policy titled Infection Prevention and Control Program and COVID-19, the facility failed to ensure infection control practices to prevent cross contamination related to entering/exiting a resident (R50) room without use of proper personal protection equipment (PPE), falling to keep the door of COVID positive resident closed, failing to ensure equipment used in a COVID positive resident's room was disinfected after use, and failing to ensure receptacles for trash and linen were located in an isolation room (COVID). In addition, the facility failed to place signage on the entrance door informing staff, family, and visitors of the COVID outbreak in the facility. This deficient practice had the potential to spread infection to staff and other residents residing in the facility.

Inspectors wroteBased on staff interview, record review, and a review of the facility policy titled Changes in a Patient's Condition, the facility failed to notify the family/health agent of a significant change related to weight loss for one of 27 sampled Residents (R) (R36). Findings Include: A review of the facility's policy titled Changes in a Patient's Condition, dated 12/30/2022, revealed it is the intent of the facility to notify the patient, his/her attending physician, and responsible party/patient representative of changes in the patient's condition and/or status. Guideline: Nursing services is responsible for notifying the patient's attending physician when: There is a significant change in the patient's physical, mental, or emotional status. Nursing services is responsible for notifying the patient, his/her next-of-kin, or responsible party/patient representative when: [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Best Practices for PASRR, the facility failed to perform Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 27 sampled residents (R) (R52) diagnosed with a mental disorder. This failure had the potential for residents with mental disorders not to receive identified specialized services.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled Patient's Plan of Care, the facility failed to develop care plans for diabetes and insulin use, as well as antianxiety and diuretic use, for one resident (R) (R 50). In addition, the facility failed to develop an individualized care plan for the behaviors related to pacing, delusions, and combativeness of one resident (R 72). The facility also failed to follow a care plan for one resident (R) 68 related to ADL care. The deficient practice had the potential to cause R50, R72, and R68 to not receive treatment and/or care according to their needs and to place them at risk for adverse consequences. The sample size was 27 residents.

Inspectors wroteBased on observation, staff interviews, and record reviews, the facility failed to provide Activities of Daily Living (ADL) care for two of 27 Residents (R) (R52 and R68) related to incontinence care and personal hygiene.

Inspectors wroteBased on observations, staff and resident interviews, record review, and a review of the facility policy titled Restorative, the facility failed to ensure one of 27 sampled Residents (R) (R19) reviewed for limited range of motion received passive range of motion exercises and splint application as needed to address limited range of motion in her right upper extremity. This failure created a potential for worsening contracture (fixed resistance to passive stretch), pain, or skin breakdown.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Weight and Nutrition Management, the facility failed to provide nutritional care and services for one of 27 sampled Residents (R) (R36) with a significant weight loss. This deficient practice had the potential to facilitate further weight loss. Findings Included: A review of the facility's policy titled Weight and Nutrition Management, dated 12/30/2022, revealed under the section titled, Guideline: The center should identify significant weight changes. The center should discuss and document the risk for significant weight changes, nutritional issues, needs, and goals in the context of the patient's overall condition and plan of care through a collaborative interdisciplinary team (IDT) environment. [...]

Inspectors wroteBased on observations, staff interview, record review and review of the facility's policy titled, Oxygen Therapy, the facility failed to maintain proper storage of respiratory equipment when not in use to prevent cross contamination related to a nasal cannula for three Residents (R) (R2, R10, and R64) who received oxygen therapy, a nebulizer mask for one resident (R10) who receive nebulizer treatments, and an oral suctioning device for one resident (R10) of 15 total residents.

Inspectors wroteBased on observations, staff and resident interviews, clinical record review, and review of the facility policy Behavior Health the facility failed to ensure behavioral health services were received and failed to monitor/document behaviors for one resident (R) 72, as it relates to administration of Ativan 2mg intramuscular on 1/2/2024 and Buspirone 5mg on 1/22/2024. The sample size was 27 residents.

Inspectors wroteBased on observations, interviews, and facility policy Labeling and Dating Tool, the facility failed to ensure that opened food items in the walk-in refrigerator, freezers, and dry storage area areas were labeled and dated. The facility census was 78, with 78 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Skilled Nursing Services: Storage Areas, the facility failed to ensure that the dumpster area was free of trash and food debris and dumpster lids and doors were closed for two of two dumpsters. This practice had the potential to harbor pests, insects, and organisms. The facility census was 78 residents.