Comer Health and Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF761Feb 26, 2026

  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… […]

• No harm, potential for more than minimal, widespreadF880Feb 26, 2026

  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. […]

• No harm, potential for more than minimal, patternF804Jan 16, 2025

  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. […]

• No harm, potential for more than minimal, patternF604Sep 29, 2022

  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 [MEDICAL RECORD OR PHYSICIAN ORDER] .' 1. Review of the electronic medical record (EMR) revealed that R#36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF656Jan 16, 2025

  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. […]