Deficiency Records for Comfort Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Comfort 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? |
|---|---|---|---|---|
| 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 | 2023-06-08 | 2023-07-27 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-06-08 | 2023-07-19 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-06-08 | 2023-07-19 | Y |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-06-08 | 2023-07-19 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-06-08 | 2023-07-19 | Y |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2023-06-08 | 2023-07-19 | Y |
| Provide training in compliance and ethics. | Health | 2023-06-08 | 2023-07-19 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-08 | 2023-07-10 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-06-08 | 2023-07-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-08 | 2023-07-07 | 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 | 2023-06-08 | 2023-07-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-07-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-08 | 2023-07-07 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-08 | 2023-07-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-06-08 | 2023-07-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-06-08 | 2023-07-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-08 | 2023-07-05 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-06-08 | 2023-07-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-08 | 2023-07-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-07-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-08 | 2023-07-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-08 | 2023-07-05 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-06-08 | 2023-07-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-05-06 | 2022-05-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-06 | 2022-05-07 | 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 | 2022-05-06 | 2022-05-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-05-06 | 2022-05-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-06 | 2022-05-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-06 | 2022-05-06 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-05-03 | 2022-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-03 | 2022-05-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-21 | 2022-04-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-21 | 2022-04-29 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-24 | 2021-09-30 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-15 | 2020-02-29 | 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 | 2020-01-15 | 2020-02-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-15 | 2020-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-15 | 2020-02-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-15 | 2020-02-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-15 | 2020-02-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-17 | 2020-02-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-01-17 | 2020-02-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-17 | 2020-02-14 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-01-17 | 2020-02-14 | 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 | 2020-01-17 | 2020-02-14 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-01-17 | 2020-02-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-17 | 2020-02-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-17 | 2020-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-17 | 2020-02-14 | N |
