Bolingreen Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Bolingreen Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 4, 2024

  Based 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. Findings include: Record review of the most recent Admission Minimum Data Set (MDS) assessment for R180, dated 12/2/2023, revealed that he had a Brief Interview for Mental Status Score (BIMS) of 15, indicating intact cognition. Exhibited no negative behaviors. Dependent on staff for all Activities of Daily Living. Has an indwelling catheter and is always incontinent of bowel and bladder. […]

• Actual harm, isolatedF697Feb 4, 2024

  Based 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. Findings include: A review of the Policy titled Pain Assessment, review date 12/30/2022, revealed Guideline; pain evaluation utilizing the 0-10 pain scale should be completed and documented on the Treatment Administration Record prior to any treatment. […]

• No harm, potential for more than minimal, widespreadF812Apr 23, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2025

  Based 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. Findings include: Review of the facility's policy titled, Storage Areas, dated [DATE], indicated, It is the intent of this center to store food in a manner that maintains quality and safety . […]

• No harm, potential for more than minimal, widespreadF880Feb 26, 2025

  Based 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. Findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 2022, indicated .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard . […]