Comfort Creek Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the kitchen's large manual can opener blade and its base, microwave oven, and food preparation pots and pans were clean and/or dry when stored and failed to cover and/or date opened food stored in one of one facility kitchen. The facility also failed to ensure an opened container of thickened apple juice was dated when opened, and discard when its best if used by date had expired in one of two nursing unit resident refrigerators. These failures had the potential to create an environment for food-borne illnesses which could affect 67 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to determine a root cause for two of two residents (R) R1 from eloping from the facility on two separate occasions and R22 wandering into other residents room. The facility's failure to determine a root cause in R1 exiting the facility and R22 entering other resodents room increases the risk of accidents or injury.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to respect resident rights when they failed to provide Activities of Daily Living (ADLs) care of their choice for two out of two dependent residents (Resident (R) R15 and R16) reviewed for ADLs assistance out of a total of 24 sampled residents. This failure had the potential to adversely affect residents' dignity, comfort, and quality of life. Findings Include: 1. Review of the facility's policy titled Resident Hygiene, dated January 2025, revealed that residents were to be bathed as needed, to include a sponge bath and/or bed bath, or more often, including a shower at least twice weekly. Review of R15's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in a secure manner for one of one resident (Resident (R)16) out of a sample size of 24. Specifically, medications requiring licensed nursing administration were stored unsecured and accessible in the resident's room, despite the resident not self administering medications. This failure placed the residents at risk for unauthorized access, misuse, and improper medication management.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe and clean environment for residents in the dining room. The facility's failure to maintain dining room chairs with cleanable surfaces without tears in the seating of the chairs has the potential to affect residents who sit in the dining room. An observation of the eating at the dining room tables on 04/27/2026 at 12:15 PM revealed five dining room chairs with tears in the seats. An interview on 04/27/2026 at 11:45 AM with the Director of Nursing (DON) confirmed the five dining room chairs with tears in the seat with the exposed non-cleanable material. The DON confirmed the chairs must be cleanable and the tears in the seats render the seat uncleanable. .

Inspectors wroteBased on observation, interview, record review, and review of Resident Assessment Instrument (RAI) manual the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was submitted for the usage of side rails for one of one resident (R) R5 reviewed for physical restraints out of a total sample of 28. The failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements, inaccurate resident care planning, and improper use of physical restraints. Findings Include: Review of R5's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated R5 was admitted on to the facility on [DATE] with diagnoses of Alzheimer's disease and cognitive communication deficit. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of out one wandering resident's (R) R22 care plan and updated with appropriate interventions. (Cross Reference F689)

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure communication sheets were completed for one of one resident (R) R8 reviewed for dialysis out of a total sample of 28 residents. This failure had the potential to affect the current facility census of 70 residents. Review of the Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed R8 was initially admitted to the facility on [DATE] with end stage renal disease, Review of R8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/2026, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R8's cognitive function was severely impaired. [...]

Inspectors wroteBased on observation interviews and review of the manufactures instructions for use, the facility failed to follow the manufacturer's instructions for the administration of insulin to one resident of one resident, (R) R55, identified by the facility as having orders for insulin administration by an insulin pen. The facility's failure to follow the manufacturer's guidelines placed residents who received insulin from an insulin pen at risk to receive an incorrect dose.

Inspectors wroteBased on family and staff interviews, record review, and review of the facility policy titled, Discharge Plan/Transfers and policy titled, Instructions for Conduction BIMS (Brief Interview for Mental Status), the facility failed to notify the responsible party of the discharge and transfer to a Personal Care Home for one out of eight sampled residents (R) with moderate cognitive impairment.

Inspectors wroteBased on record review, resident and staff interviews, and review of the facility's policy titled, Discharge Plan/Transfers, the facility failed to ensure a written transfer notice that contained all required information was provided to four of four residents and/or their representative (Resident (R) 65, R72, R68, and R25) reviewed for facility-initiated emergent hospital transfer out of 28 sample residents. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.

Inspectors wroteBased on staff interviews, family interview, record review, and review of the facility's policy titled, Change of Condition/Reporting, the facility failed to provide a timely notification of change in condition for a resident that became unresponsive, breathless, and Cardiopulmonary Resuscitation (CPR) was initiated for one of one resident (Resident (R) 385) reviewed for notification of change in condition of 28 sample residents. This failure had the potential to affect the families' grieving process.

Inspectors wroteBased on record review, interviews, and review of facility policy titled, Freedom from Abuse Standard Addendum, the facility failed to protect the residents' right to be free from physical abuse by other residents for two of three residents (Resident (R) 65 and R54) reviewed for abuse out of 28 sample residents. The facility's failure to protect residents from abuse placed residents at continued risk of harm.

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled, Bed Hold, the facility failed to provide a written bed hold notice upon transfer to the hospital for one of four residents and/or representative (Resident (R) 25) reviewed for hospitalization out of 28 sample residents. This failure had the potential to cause R25 confusion or distress regarding returning to the same room after hospitalization.

Inspectors wroteBased on record review, interviews, and review of the facility's document titled, RAI [Resident Assessment Instrument]/Care Planning Management, the facility failed to ensure the residents participated in care conferences for one of 28 sample residents (Resident (R) 65) reviewed for care conferences. This failure had the potential for the residents to have unmet care needs.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Physician Services, the facility failed to follow the physician's orders for one of eight sampled residents (R) (R5).

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to provide tracheostomy care, supervision, and supplies for a resident who was care planned to self-care his own tracheostomy site to one of two residents (Resident (R) 13) reviewed for respiratory care of 28 sample residents. This failure had the potential to contribute to respiratory infection for R13.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policies titled, Behavior Management Standard, and Depression Management, the facility failed to ensure psychotropic medications' efficacy was monitored, and non-pharmacological interventions were offered and included in the care plan for two of two residents (Resident (R) 13 and R49) reviewed for unnecessary and/or psychotropic medications of 28 sample residents. This failure had the potential to affect a physician's decision to prescribe the lowest possible effective dose of medication.

Inspectors wroteBased on staff interviews, record reviews, and a review of the facility's policy titled Emergency Response Management Cardiopulmonary Resuscitation (CPR), the facility failed to activate 911 and continue CPR until more aggressive life-sustaining treatment could be initiated for one resident (R1) of 14 residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:14 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. [...]

Inspectors wroteBased on staff interviews, record review, and a review of the Administrator and Director of Nursing (DON) Job Description, the Administration failed to ensure that staff were following appropriate procedure when providing Cardiopulmonary Resuscitation (CPR) for one resident (R1) of 14 residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and DON were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:14 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. An Acceptable Removal Plan was received on [DATE]. [...]

Inspectors wroteBased on observation, record review, staff and resident interviews the facility failed to document administered bathing for two of three sampled residents (R) (5 and R10) and failed to provide setup and clean up after a meal for one resident (R) (10). This failure had the potential to negatively impact residents quality of life and decrease functional status.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policies titled, Administration of Enteral Feedings: Continuous and Diet Ordering the facility failed to have start and stop times for a continuous enteral feeding for two of two residents (R) (5 and 11) and failed to have a complete diet order for one of one resident (R) (11).

Inspectors wroteBased on observations and staff interviews the facility failed to ensure that a safe, clean, and home like environment was maintained for six of 10 room on the E hall, and three of eight rooms on the D hall. This failure had the potential to place residents at risk for the use of unsanitary and unsafe environments and a potential for diminished quality of life. During the initial tour of the facility on 10/6/2023 at 8:40 am the following environmental concerns were observed: Observation on D and E halls revealed floors scuffed up with dark black streaks down hallway and in residents' rooms. D hall had three of eight rooms observed floors and room doors with dark streaks. E hall had six of 10 rooms observed floors and room doors with dark streaks. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Pre-admission Screening and Resident Review, the facility failed to complete a new Pre-admission Screening and Review (PASRR) level II after admission to the facility to include resident (R) R46, R90, R43 and R16. This had the potential to affect four of six residents reviewed with a qualifying psychological diagnosis.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provided treatment and care in accordance with professional standards for one of 32 sampled residents (R) (R244) related to (1) failed to assess and monitor bruises to bilateral arms and failed to follow physician orders related to weekly skin audits.