Deficiency Records for Comfort Creek Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Comfort Creek Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-30 | 2024-01-01 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-30 | 2024-01-01 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-08 | 2023-11-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-08 | 2023-11-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-08 | 2023-11-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-07 | 2023-11-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-07 | 2023-11-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-07 | 2023-11-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-02 | 2023-05-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-02 | 2023-03-19 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-02 | 2023-03-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-02 | 2023-03-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-02 | 2023-03-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-02-02 | 2023-03-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-02 | 2023-03-19 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-02 | 2023-03-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-02 | 2023-03-19 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-02-02 | 2023-03-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-02 | 2023-03-19 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-02-02 | 2023-03-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-02 | 2023-03-19 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-02-02 | 2023-03-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-02 | 2023-03-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-02 | 2023-03-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-02 | 2023-03-19 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-01-30 | 2023-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-30 | 2023-03-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-30 | 2023-03-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-30 | 2021-06-14 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-13 | 2021-06-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-13 | 2021-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-13 | 2021-06-05 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-13 | 2021-06-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-13 | 2021-06-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-13 | 2021-06-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-13 | 2021-06-05 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-05-13 | 2021-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-13 | 2021-06-05 | N |
