Comfort Creek Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Comfort Creek Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jun 7, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF835Jun 7, 2024

  Based 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]. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2026

  Based 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. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF727Feb 2, 2023

  Based on staff interviews, record review, and a review of the facility policy titled, Clinical Staffing Standard, the facility failed to ensure the required Registered Nurse (RN) coverage of at least eight consecutive hours per day, seven days per week. There was no RN scheduled, or the Director of Nursing (DON) repeatedly served as the RN over a three-month period, although the facility census, which was higher than 60 residents per day, prohibited the DON from also serving as a charge nurse. […]

• No harm, potential for more than minimal, widespreadF802Feb 2, 2023

  Based on observation, interview, review of the dietary staffing schedules, and review of facility policy, the facility failed to have sufficient dietary staff to ensure food was stored, prepared, and served in a sanitary and safe manner. Routine cleaning schedules were not followed due to a lack of sufficient staff to perform these duties, and food preparation surfaces, equipment, dishes, and service/cooking ware were found not to be clean and/or in good repair. Foods were not dated/labeled and/or sealed, and equipment, such as scoops, was not stored in a manner to prevent contamination. […]