Colonel Glenn Health and Rehab, LLC

Inspectors wroteBased on record review, observation, interviews, facility documentation review, and facility policy review, it was determined that the facility failed to prevent a rash from spreading between residents in different rooms, on two different halls and two separate floors when reviewed for infection control and prevention for one of one infection control plan

Inspectors wroteBased on record review and interview, the facility failed to ensure minimum data set (MDS) assessments were transmitted after completion for 8 (Residents #4, #32, #47, #49, #55, #58, #76, #88) of 8 sampled residents reviewed for resident assessments.

Inspectors wroteBased on observation, record review, interview, policy review, and the review of the menu, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents during 1 of 2 meals observed being prepared in the kitchen.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure expired food items were promptly removed / discarded on or before the expiration or use by date; Dietary staff washed their hands between dirty and clean tasks and before handling clean equipment; Cold food items were at 41 degrees Fahrenheit or below on ice while awaiting service for 2 of 2 meals observed; ensure meals were served at a safe and appetizing temperature to prevent possible food born illnesses for 1 (Resident #84) of 1 sampled resident.

Inspectors wroteBased on facility record review and interview, it was determined that the facility failed to update resident care plans to reveal an accurate code status (Full Code status changed to a Do Not Resuscitate (DNR) status) for 1 (Resident #5) of 2 residents sampled for revisions or updates to the care plan.

Inspectors wroteBased on observation, interview, record review, and facility document review, the facility failed to implement fall prevention interventions for 1 resident (Resident #58) of 3 residents reviewed for fall prevention.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a urinary catheter drainage bag was not directly touching the floor for 1 (Resident #216) of 1 sampled resident reviewed for urinary catheter care.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items stored in the refrigerator and storage area were covered or sealed to maintain freshness and prevent potential cross contamination of food and beverages, that expired food items were promptly remove/discarded by the expiration or use by dates, that kitchen vents and ceiling tiles were cleaned to provide a sanitary environment for food preparation, and that baseboards were not missing and were free of chips, debris, rust, and dirt, that 1 of 2 ice scoop ice machines was maintained in clean and sanitary condition to prevent food and beverages contamination, that staff washed hands before handling clean equipment or food items to minimize the potential for contaminating food items for residents who received meals from 1 of 1 kitchen, and that hot food items were maintained at or above 135 degrees Fahrenheit while [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to accurately assess the Minimum Data Set [MDS] accurately reflected on Section J1800, any falls since Admission/Entry or Reentry or Prior Assessment, a history of falls affecting 1 sampled (Resident #68) of 4 residents with falls on 2A. The facility failed to update the Minimum Data Set [MDS] with a discharge with anticipation to return in a timely manner for 1 (Resident #32) of 46 residents discharged in the last 120 days.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 2 (Resident #33, and #73) of 5 sampled residents. The facility failed to store oxygen tubing appropriately when not in use to prevent possible respiratory complications for 1(Resident #27) of 5 sampled residents. This failed practice had the potential to affect 15 residents that had physicians' orders for Oxygen as documented on a list provided by the Director of Nursing on 02/15/24 at 3:50 PM.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a call light was in reach for 1 Resident #3 of 4 sampled residents (Residents #69; #86; #91) who utilize the call light on unit 1-D. The facility failed to ensure that call lights located in the resident's bathroom were equipped with a device that would enable them to reach the call light should they fall for 1 Resident #34 who resides on unit 1-B and 2 Residents #86 and #399 sampled residents who reside on unit 1-D.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that 1 (Resident #76) of 2 sampled residents on 2 C had a hand roll as care planned for an intervention.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an accident/hazard free environment was provided for 1 Resident (#10) resident in the case mix. This failed practice had the potential to affect 7 ambulatory residents who resided on hall 1-D.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that 1 (Resident #39) resident received proper incontinence care. This failed practice had the potential to cause skin breakdown, poor hygiene, and/or infection. This failed practice had the potential to affect 4 Residents on 2B hall dependent on staff to provided incontinence care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for the following Residents (#3, #6, #7).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the connector for an internal feeding was stored properly for Resident #5.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Resident and/or Responsible Party was notified of medication changes related to diabetic medications for 1 (Resident #2) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents.

Inspectors wroteBased on record review, and interview, the facility failed to ensure the Resident Representative with concerns and complaints regarding discontinued medication notification were allowed to be voiced through grievances as part of the process of Resident Rights for 1 (Resident #2) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation and interview, the facility failed to ensure food items were promptly removed and/or discarded on or before the expiration or use by date to prevent the growth of bacteria; failed to ensure food items were dated, covered or sealed to prevent cross contamination for residents who received meals from 1 of 1 kitchen; failed to ensure two jars of jelly were stored in the refrigerator after opening to prevent potential for spoilage; failed to ensure the deep fryer, cooking utensils, appliances and a food rack were maintained in clean condition to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure there was not a broken/missing tile at the entrance of the dish room; failed to ensure proper handling of plates to prevent the potential for food borne illness; [...]

Inspectors wroteBased on record review and interview, the facility failed to transmit the Minimum Data Set (MDS) within 14 days of the Completion Date for 2 (Residents #53 and #80) of 3 (Residents #14, #53 and #80) sampled residents whose MDS were reviewed for timely transmission.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide nail care for a resident who was unable to carry out Activities of Daily Living (ADL) to maintain good grooming and personal hygiene for 1 (Resident #49) of 7 (Residents #9, #14, #45, #46, #49, #70 and #98,) sampled residents on 1A and 1B halls who were dependent or required assistance with nail care as documented on a list provided by the Administrator on 12/21/22 at 8:47 a.m.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care and services to address residents positioning needs for two (Residents #73 and #35) of 10 (Residents #1, #9, #14, #17, #18, #35, #58, #73, #94, and #104) sampled residents who had limited Range of motion and/or contractures as documented on a list provided by the Administrator on 12/21/22.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a urinary catheter drainage bag was maintained in a privacy bag to maintain privacy and dignity for 1 (Resident #70); failed to ensure the urinary catheter drainage bag was kept off the floor to prevent the potential for infection for 1 (Resident #70) and failed to ensure the catheter drainage bag was maintained below the level of the bladder to prevent the potential for infection for 2 (Residents #73 and #76) of 6 (Residents #9, #16, #70, #73, #76 and #94) sampled residents who had a urinary catheters.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fluids were readily accessible to promote adequate hydration for 3 (Residents #70, #73 and #94) of 30 (Residents #1, #3, #9, #14, #16, #17, #18, #21, #25, #29, #33, #35, #41, #45, #46, #49, #58, #63, #64, #66, #67, #70, #73, #76, #82, #89, #92, #94, #98 and #105) sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an oxygen nasal cannula tubing was stored in accordance with professional standards of practice when not in use for 2 (Residents #82 and #63); failed to ensure Oxygen in Use signs were posted on the doors of 2 (Residents #46 and #82) and tubing was changed out per physicians orders for 2 (Residents #63 and #82) of 6 (Residents #16, #46, #63, #64, #70 and #82) sampled residents who had a physician's order for oxygen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were locked in a secured cart and not left in a resident's room to prevent accidental ingestion by ambulatory residents and/or residents who were independently mobile for 3 (Resident #58, #66 and #82) of 3 sampled residents. This failed practice had the potential to affect 7 residents who were ambulatory with or without a device who resided on 2A and 2B Halls as documented on a list provided by the Administrator on 12/21/22 at 8:47 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the menu was followed for two meals observed for 8 (Residents #1, #18, #25, #35 #66, #67 and #70 this is only seven) who had a physician ' s order for a mechanical soft and/or an enhanced or pureed diet to ensure nutritional wellbeing.

Inspectors wroteBased on record review and interview, the facility failed to complete a Significant Change in Status (SCSA) Minimum Data Set for 1 (Resident #9) of 25 (Residents #1, #3, #9, #16, #17, #21, #25, #29, #35, #45, #46, #49, #58, #63, #67, #70, #73, #76, #82, #89, #92, #94, #98, #115 and #116,) sampled residents whose MDS was reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to identify residents positioning needs for two (Residents #73 and #35) of 10 (Residents #1, #9, #14, #17, #18, #35, #58, #73, #94, and #104) sampled residents who had limited range of motion and/or contractures as documented on a list provided by the Administrator on 12/21/22.

Inspectors wroteBased on record review and interview, the facility failed to revise the resident Care Plan to meet the residents' needs for 1 (Resident #82) of 24 (Residents #3, #9, #11, #16, #17, #21, #25, #29, #35, #45, #46, #49, #58, #63, #67, #70, #73, #76, #82, #89, #92, #94, #98 and #115) sampled residents whose Care Plans were reviewed.

Inspectors wroteBased on observation and record review, the facility failed to ensure the diagnosis for the medication was relevant to the class of the medication ordered to minimize the potential for complications for 1 (Resident #16) of 3 (Residents #16, #29 and #35) sampled residents who had Physician Orders for Seroquel.