Comfort Care Nursing Center

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent an unsupervised exit from the facility, when the resident exited the facility unsupervised and remained outside unattended for approximately two (2) minutes before staff redirected him back into the facility for one (1) of three (3) residents reviewed for supervision.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to foods not dated, foods not labeled, foods not properly sealed, overly ripe produce and unsanitary handling of ready to eat foods for two (2) of two (2) kitchen observations.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to review and resolve multiple resident grievances in a timely and effective manner, resulting in ongoing unaddressed environmental concerns expressed during three (3) of 3 consecutive months of Resident Council meetings.

Inspectors wroteBased on interviews and record reviews, and facility policy review the facility failed to ensure that staff reported allegations of verbal abuse involving two (2) of three (3) residents reviewed for verbal abuse (Resident #66 and #93), and failed to report multiple allegations of misappropriation of resident property (money) involving five (5) of 14 residents in Resident Council (Residents #5, #8, #17, #38, and #81) to the State Agency (SA), as required by federal regulations.

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed to ensure that residents were treated with dignity and respect by licensed nursing staff for two (2) of four (4) residents reviewed for resident rights (Resident #66 and #93). Findings Include:A record review of facility policy titled Resident's Rights Policy revealed the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. On 9/29/25 at 11:43 AM, Resident #66 reported that night shift Licensed Practical Nurse (LPN)#1 raised her voice during a medication pass and spoke in a demeaning and intimidating tone. The resident stated she felt as though she was talked down to like a child. She also expressed fear of retaliation and concern for other residents who might not be able to speak up. On 9/29/25 at 2: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' right to be free from verbal abuse by staff for two (2) of three (3) residents reviewed for abuse (Residents #66 and #93).

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to protect residents from misappropriation of resident funds and failed to implement corrective action or reimburse residents after funds were reported missing, affecting five (5) of 14 residents interviewed in Resident Council (Residents #5, #8, #17, #38, and #81).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that medications and biologicals were securely stored to prevent access by unauthorized individuals for one (1) of four (4) days of survey.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the physician and the resident's representative of the initiation of psychosocial services for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, and #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to ensure that the physician and resident representative (RR) were informed when 1:1 psychosocial therapy services were initiated by a third-party provider. Findings Included: A review of the facility's Resident Rights Notification of Changes Policy, reviewed date 05/30/2025 revealed, It is the policy of (Proper Name of Facility) to notify the resident; consult with the physician; and notify, consistent with his or her authority, the resident representative of changes as discussed in the policy . [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to develop a comprehensive care plan that included all services provided to address the psychosocial needs of three (3) of three (3) sampled residents receiving individual psychosocial therapy (Residents #4, #5, and #6), with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to include ongoing psychosocial therapy services provided by the Licensed Clinical Social Worker (LCSW) in the residents care plans to ensure coordination of care, consistent monitoring, and individualized interventions based on the residents' psychosocial needs.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure services were provided and documented according to professional standards for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the facility failed to obtain a physician's order for ongoing psychosocial therapy services provided by a third party Licensed Clinical Social Worker (LCSW), resulting in services being delivered without appropriate physician oversight.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to identify, assess, and coordinate behavioral health services for three (3) of three (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, and #6, with the potential to affect all 21 residents receiving these services. Specifically, the facility allowed a Licensed Certified Social Worker (LCSW) to provide ongoing cognitive behavioral therapy within the facility without physician oversight, formal referral, or interdisciplinary coordination in which she accepted self-referred residents, regardless of whether clinical need had been identified. Findings Included: [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure complete and readily accessible medical records were maintained for (3) of (3) sampled residents receiving individual psychosocial therapy, Residents #4, #5, #6, with the potential to affect all 21 residents receiving psychosocial therapy. Specifically, the therapist maintained resident therapy documentation separately from the facility's medical record and did not share or integrate the documentation into the residents' facility medical records.

Inspectors wroteBased on staff interview and record review, the facility failed to electronically submit accurate direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for one (1) of three (3) months reviewed.