Inspection Reports for
Comfort Creek Nursing and Rehabilitation Center
10200 U.S. HWY 1 SOUTH, WADLEY, GA, 30477
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
14.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
204% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
78% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Comfort Creek Nursing and Rehabilitation Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
A revisit survey was conducted from June 3, 2025, through June 4, 2025, to verify correction of deficiencies cited in the April 17, 2025, recertification survey.
Findings
All deficiencies cited in the April 17, 2025, recertification survey were found to be corrected during this revisit survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Comfort Creek Nursing and Rehabilitation Center following a survey completed on June 4, 2025.
Findings
The document contains initial comments but does not provide specific details of deficiencies or findings.
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
A revisit survey was conducted from June 3, 2025, through June 4, 2025, to verify correction of deficiencies cited in the April 17, 2025, complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on April 17, 2025, and all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the April 17, 2025, complaint survey were found to be corrected.
Report Facts
Facility census: 76
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Life Safety
Census: 79
Capacity: 98
Deficiencies: 1
Date: Apr 21, 2025
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with the Life Safety Code requirements due to an improperly mounted exit sign near the front nurse station that allowed smoke migration, affecting one of four smoke compartments.
Deficiencies (1)
Exit sign near the front nurse station was pulled down from the ceiling, allowing migration of smoke.
Report Facts
Census: 79
Total Capacity: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding the improperly mounted exit sign |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide timely notification of change in condition, failure to protect residents from abuse, failure to provide written bed hold notices, failure to ensure resident participation in care conferences, failure to follow physician orders during CPR, failure to provide appropriate tracheostomy care and supplies, and failure to monitor efficacy and side effects of psychotropic medications and to provide non-pharmacological interventions.
Deficiencies (7)
F 0580: The facility failed to provide timely notification of change in condition for a resident who became unresponsive and required CPR, delaying family notification until after the resident was pronounced deceased.
F 0600: The facility failed to protect two residents from physical abuse by other residents, resulting in physical altercations and minor injuries.
F 0625: The facility failed to provide a written bed hold notice upon hospital transfer for one resident, potentially causing confusion about bed reservation.
F 0657: The facility failed to ensure one resident participated in care conferences, potentially leading to unmet care needs.
F 0684: The facility failed to follow physician orders during CPR for one resident, stopping and resuming CPR contrary to orders, and failed to provide appropriate treatment and care according to orders.
F 0695: The facility failed to provide safe and appropriate tracheostomy care, supervision, and supplies for one resident who self-cared, risking respiratory infection.
F 0758: The facility failed to monitor efficacy and side effects of psychotropic medications and failed to offer or document non-pharmacological interventions for two residents receiving such medications.
Report Facts
Residents reviewed: 28
Physical altercations: 2
Discharges and returns: 6
Care conferences: 1
CPR incidents: 2
Tracheostomy care: 1
Residents on psychotropic medications: 2
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 17, 2025
Visit Reason
A State Licensure survey was conducted at Comfort Creek Nursing and Rehabilitation Center from April 14, 2025, through April 17, 2025, to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey identified multiple deficiencies including failure to promptly notify family of a resident's change in condition leading to death, failure to provide written bed hold notices upon hospital transfers, and inadequate monitoring and documentation of psychotropic medication efficacy and nonpharmacological interventions for residents with depression and insomnia.
Deficiencies (3)
Failure to provide timely notification of change in condition for a resident who became unresponsive and required CPR.
Failure to provide a written bed hold notice upon transfer to the hospital for a resident.
Failure to monitor efficacy and side effects of psychotropic medications and to include nonpharmacological interventions in care plans for residents with depression and insomnia.
Report Facts
Number of sample residents reviewed: 28
Number of hospital discharges for Resident 25: 6
BIMS score: 99
BIMS score: 15
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN3 | Licensed Practical Nurse | Documented CPR initiation and attempts to notify Medical Director and Director of Nursing |
| LPN5 | Licensed Practical Nurse | Found resident unresponsive and initiated CPR |
| Director of Nursing | Director of Nursing | Confirmed delayed notification to family and lack of call rotation |
| Revenue Cycle Manager | Revenue Cycle Manager | Explained bed hold policy related to Veterans Affairs payer source |
| Unit Manager 2 | Unit Manager | Supported staff during emergency and commented on family notification |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 17, 2025
Visit Reason
A State Licensure survey was conducted at Comfort Creek Nursing and Rehabilitation Center from April 8, 2025, through April 17, 2025, to assess compliance with state health regulations.
Findings
The survey revealed there were no State Health deficiencies cited at the facility.
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 7
Date: Apr 17, 2025
Visit Reason
A standard annual survey was conducted from April 14, 2025 through April 17, 2025, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Comfort Creek Nursing and Rehabilitation Center.
Complaint Details
Complaint Intake numbers GA00248458, GA00248178, GA00248247, GA00252804, GA00247732, and GA00250432 were investigated. Five complaint intakes were unsubstantiated, and Complaint Intake Number GA00248458 was substantiated with deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely notify family of a resident's change in condition resulting in death, failure to protect residents from physical abuse by other residents, failure to provide written transfer and bed hold notices, failure to ensure resident participation in care conferences, failure to provide proper tracheostomy care and supplies, and failure to monitor psychotropic medication efficacy and non-pharmacological interventions.
Deficiencies (7)
Failure to provide timely notification of change in condition for a resident who became unresponsive and required CPR.
Failure to protect residents from physical abuse by other residents.
Failure to provide written transfer notices containing all required information to residents and/or their representatives upon facility-initiated emergent hospital transfers.
Failure to provide written bed hold notice upon transfer to hospital for a resident.
Failure to ensure resident participation in care conferences.
Failure to provide tracheostomy care, supervision, and supplies for a resident who was care planned to self-care his own tracheostomy site.
Failure to ensure psychotropic medications' efficacy was monitored and non-pharmacological interventions were offered and included in the care plan for residents receiving such medications.
Report Facts
Complaint Intake Numbers Investigated: 6
Complaint Intake Numbers Unsubstantiated: 5
Complaint Intake Numbers Substantiated: 1
Resident Census: 81
Resident Sample Size: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN3 | Licensed Practical Nurse | Documented CPR initiation and attempted notifications during resident R385's change in condition |
| LPN5 | Licensed Practical Nurse | Found resident R385 unresponsive and initiated CPR |
| DON | Director of Nursing | Confirmed delayed notification to family and lack of call rotation; involved in multiple interviews regarding deficiencies |
| UM1 | Unit Manager | Provided information on resident-to-resident abuse incident and transfer/discharge notice practices |
| UM2 | Unit Manager | Responded to notification of resident R385's unresponsiveness and family notification |
| Administrator | Provided statements regarding resident-to-resident abuse and care conference participation | |
| LPN6 | Licensed Practical Nurse | Provided information on resident R65's behavior and transfer/discharge notice practices |
| LPN7 | Licensed Practical Nurse | Stated treatment nurse provided tracheostomy care, not herself |
| LPN8 | Licensed Practical Nurse | Observed lack of tracheostomy supplies and care for resident R13 |
| RCM | Revenue Cycle Manager | Provided information on bed hold policies related to VA payor source |
Inspection Report
Abbreviated Survey
Census: 81
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint intake numbers GA00254536, GA00254535, and GA00254548. The survey was initiated on April 8, 2025, and concluded on April 17, 2025.
Complaint Details
Complaint Intake number GA00254548 was unsubstantiated. Complaint Intake numbers GA00254536 and GA00254535 were substantiated with no deficiencies.
Findings
Complaint Intake number GA00254548 was unsubstantiated, and Intake numbers GA00254536 and GA00254535 were substantiated with no deficiencies. The facility was cited for a deficiency related to failure to follow a physician's orders for one resident (R5), specifically regarding the administration and cessation of CPR.
Deficiencies (1)
Failure to follow the physician's orders for one of eight sampled residents (R5), including improper administration and cessation of CPR contrary to physician's orders.
Report Facts
Complaint Intake numbers investigated: 3
Census: 81
Sampled residents: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Registered Nurse | Arrived at the facility to pronounce resident R5 |
| CC | Licensed Practical Nurse | Present during CPR event on resident R5 |
| FF | Registered Nurse | Called Administrator to inform resident R5 had coded |
| BB | Licensed Practical Nurse | Participated in CPR event on resident R5 |
| AA | Licensed Practical Nurse | Participated in CPR event on resident R5 |
| RNC | Regional Nurse Consultant | Provided guidance on CPR continuation until EMS arrival |
| Administrator | Instructed staff to continue CPR until EMS arrived | |
| DON | Director of Nursing | Stated nurses should have followed physician's orders to stop CPR |
| MD | Medical Director | Gave order to stop CPR and stated no order was given to resume CPR |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide timely notification of change in condition, failure to protect residents from abuse, failure to provide timely transfer/discharge notices, failure to provide written bed hold notices, failure to ensure resident participation in care conferences, failure to provide appropriate respiratory care, and failure to monitor psychotropic medication efficacy and non-pharmacological interventions.
Complaint Details
The complaint investigation substantiated failures in timely notification of change in condition, protection from abuse, transfer/discharge notice provision, bed hold notice provision, resident participation in care conferences, respiratory care, and psychotropic medication monitoring.
Findings
The facility failed to timely notify family of a resident's change in condition resulting in delayed notification of death. The facility failed to protect residents from physical abuse by other residents. The facility did not provide timely written transfer/discharge notices or bed hold notices to residents or their representatives. One resident was not invited to care conferences. The facility failed to provide adequate tracheostomy care and supplies for a resident. Psychotropic medications were not properly monitored for efficacy or side effects, and non-pharmacological interventions were not documented or offered as required.
Deficiencies (7)
F 0580: The facility failed to provide timely notification of change in condition for a resident who became unresponsive and required CPR, delaying family notification until after death was pronounced.
F 0600: The facility failed to protect residents from physical abuse by other residents, resulting in physical altercations and injuries to two residents.
F 0623: The facility failed to provide written transfer/discharge notices to four residents and/or their representatives upon hospital transfers.
F 0625: The facility failed to provide a written bed hold notice to one resident and/or representative upon hospital transfer, causing potential confusion about bed reservation.
F 0657: The facility failed to ensure one resident participated in care conferences, as the resident was not invited or aware of the meetings.
F 0695: The facility failed to provide adequate tracheostomy care, supervision, and supplies for a resident who self-cared his tracheostomy, including failure to change a brown, unclean inner cannula for over a year.
F 0758: The facility failed to monitor efficacy and side effects of psychotropic medications and failed to offer or document non-pharmacological interventions for two residents receiving such medications.
Report Facts
Residents reviewed: 28
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Inspection Report
Re-Inspection
Census: 77
Deficiencies: 0
Date: Jul 29, 2024
Visit Reason
A Revisit Survey was conducted on July 29, 2024 to verify correction of deficiencies cited during the June 7, 2024 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on June 7, 2024; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the June 7, 2024 Complaint Survey were found to be corrected.
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 2
Date: Jun 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to properly activate emergency medical services and continue CPR for a resident (R1) with full code status during a cardiac emergency.
Complaint Details
The complaint investigation substantiated that the facility failed to call 911 during CPR for resident R1, who had a full code status. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Findings
The facility failed to call 911 during CPR for resident R1, who subsequently expired. Staff did not follow the facility's Emergency Response Management policy. The facility lacked an AED or defibrillator. Immediate Jeopardy was identified and later removed after corrective actions including staff re-education and policy reinforcement.
Deficiencies (2)
F 0678: The facility failed to activate 911 and continue CPR until more aggressive life-sustaining treatment could be initiated for one resident (R1) of 14 reviewed for code status.
F 0835: The administration failed to ensure staff followed appropriate CPR procedures, including notifying 911 during CPR for one resident (R1) of 14 reviewed for code status.
Report Facts
Residents reviewed for code status: 14
Residents elected full code: 58
Residents elected Do Not Resuscitate: 21
Licensed nurses with CPR certification: 11
Licensed staff educated on Emergency Response Management: 86.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Assisted in CPR, failed to call 911 during code for resident R1 |
| RN CC | Registered Nurse | Assisted in CPR, pronounced resident R1, failed to document EMS call |
| LPN BB | Licensed Practical Nurse | Assisted in CPR, called Medical Director during code for resident R1 |
| Director of Nursing | Director of Nursing | Confirmed no EMS call documentation, responsible for CPR education |
| Administrator | Facility Administrator | Informed of Immediate Jeopardy, involved in corrective action and education |
| Medical Director | Medical Director | Gave order to stop CPR during resident R1's code |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Comfort Creek Nursing and Rehabilitation Center following a survey completed on January 9, 2024.
Findings
The document contains an initial comment section but does not provide specific details on deficiencies or findings within the visible content.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the November 30, 2023 Complaint Investigation survey.
Complaint Details
The visit was a follow-up to a complaint investigation conducted on November 30, 2023. All cited deficiencies were corrected.
Findings
All deficiencies cited in the prior complaint investigation survey were found to be corrected during this revisit survey.
Report Facts
Census: 86
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 30, 2023
Visit Reason
A State Licensure survey was conducted at Comfort Creek Nursing and Rehabilitation Center from November 21, 2023 through November 30, 2023 to assess compliance with state health regulations.
Findings
The facility failed to document start and stop times for continuous enteral feedings for two residents and lacked a complete diet order for one resident, potentially risking inadequate nutritional intake. Additionally, the facility failed to document bathing for two residents and did not provide setup and cleanup assistance after meals for one resident, potentially impacting residents' quality of life and functional status.
Deficiencies (4)
Failed to have start and stop times for continuous enteral feeding for two residents (R5 and R11).
Failed to have a complete diet order for one resident (R11).
Failed to document administered bathing for two residents (R5 and R10).
Failed to provide setup and clean up after a meal for one resident (R10).
Report Facts
Duration of enteral feeding: 22
Number of showers received: 5
Number of showers received: 6
Number of showers received: 2
Number of showers received: 1
Number of showers received: 1
BIMS score: 99
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Licensed Practical Nurse (LPN) | Stated enteral feeding order for R11 lacked start and stop times |
| CC | Licensed Practical Nurse (LPN) | Reported on R5's condition and care |
| DD | Certified Nurse Aide (CNA) | Described shower schedules and bathing documentation |
| AA | Certified Nurse Aide (CNA) | Provided information on R10's meal assistance and feeding |
| BB | Registered Nurse (RN) | Described R10's eating behaviors and assistance needs |
| EE | Restorative Certified Nurse Aide (CNA) | Stated R10 was assigned meal setup and variable ADL abilities |
| DON | Director of Nursing | Provided clarifications on feeding orders, documentation, and nursing expectations |
| ST | Speech Therapist | Discussed feeding orders and pleasure food recommendations for R11 |
| Director of Rehabilitation | Stated no complete order for pleasure food for R11 | |
| Unit Manager (UM) | Discussed therapy recommendations and medical director involvement |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Date: Nov 30, 2023
Visit Reason
An abbreviated/Partial Extended Survey was conducted to investigate multiple complaint intake numbers initiated on 2023-11-21 and concluded on 2023-11-30. Some complaints were substantiated with deficiencies cited, others were unsubstantiated or substantiated with no deficiencies.
Complaint Details
Complaint Intake numbers GA00235999 and GA00241037 were substantiated with deficiencies cited. Complaint Intake numbers GA00236069, GA00236986, and GA00239731 were substantiated with no deficiencies. Complaint Intake numbers GA00238983 and GA00239586 were unsubstantiated.
Findings
The facility failed to document administered bathing for two of three sampled residents and failed to provide setup and clean up after a meal for one resident, potentially impacting quality of life and functional status. Additionally, the facility failed to have start and stop times for continuous enteral feeding for two residents and lacked a complete diet order for one resident, risking inadequate nutritional intake.
Deficiencies (2)
Failed to document administered bathing for two residents and failed to provide meal setup and clean up for one resident.
Failed to have start and stop times for continuous enteral feeding for two residents and failed to have a complete diet order for one resident.
Report Facts
Complaint Intake numbers investigated: 7
Census: 90
Feeding pump rate: 55
Feeding pump duration: 22
Feeding pump rate: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Interviewed regarding resident R5's condition and care. |
| DD | Certified Nurse Aide (CNA) | Interviewed about shower schedules and bathing documentation. |
| AA | Certified Nurse Aide (CNA) | Interviewed about care provided to resident R10. |
| BB | Registered Nurse (RN) | Interviewed about resident R10's eating behaviors and assistance needs. |
| EE | Restorative Certified Nurse Aide (CNA) | Interviewed about resident R10's ADL and movement abilities. |
| FF | Licensed Practical Nurse (LPN) | Interviewed about enteral feeding orders for resident R11. |
| DON | Director of Nursing | Provided information about documentation requirements and feeding protocols. |
| UM | Unit Manager | Discussed therapy recommendations and medical director involvement. |
| ST | Speech Therapist | Interviewed regarding feeding and pleasure food recommendations for resident R11. |
| Director of Rehabilitation | Interviewed about completeness of pleasure food orders for resident R11. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 30, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with care standards, focusing on activities of daily living assistance and enteral feeding practices.
Findings
The facility failed to document bathing for two residents and failed to provide meal setup and cleanup assistance for one resident, potentially impacting quality of life. Additionally, the facility failed to have start and stop times for continuous enteral feedings for two residents and lacked a complete diet order for one resident, risking inadequate nutritional intake.
Deficiencies (2)
F 0677: The facility failed to document bathing for two residents and failed to provide meal setup and cleanup assistance for one resident, risking decreased functional status and quality of life.
F 0693: The facility failed to have start and stop times for continuous enteral feeding for two residents and lacked a complete diet order for one resident, risking inadequate nutritional intake.
Report Facts
Showers documented for resident R5: 5
Showers documented for resident R5: 6
Showers documented for resident R10: 2
Showers documented for resident R10: 1
Showers documented for resident R10: 1
Enteral feeding rate for resident R5: 55
Enteral feeding duration for resident R5: 22
Enteral feeding rate for resident R11: 75
Enteral feeding duration for resident R11: 22
Pleasure snack frequency for resident R11: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA DD | Certified Nurse Aide | Interviewed regarding shower schedules and bathing documentation |
| LPN CC | Licensed Practical Nurse | Interviewed about resident R5's condition and bathing |
| CNA AA | Certified Nurse Aide | Interviewed about resident R10's meal assistance |
| RN BB | Registered Nurse | Interviewed about resident R10's eating behaviors |
| Restorative CNA EE | Certified Nurse Aide | Interviewed about resident R10's ADL and movement abilities |
| Director of Nursing | Director of Nursing | Interviewed about documentation requirements and feeding orders |
| LPN FF | Licensed Practical Nurse | Interviewed about enteral feeding orders for resident R11 |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed about diet orders for resident R11 |
| Speech Therapist | Speech Therapist | Interviewed about pleasure feeding recommendations for resident R11 |
| Unit Manager | Unit Manager | Interviewed about therapy recommendations and feeding orders |
Inspection Report
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Comfort Creek Nursing and Rehabilitation Center, indicating a regulatory inspection was completed.
Findings
The report contains an initial comment section but does not provide any detailed findings or deficiencies on the page provided.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/8/2023 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies at Comfort Creek Nursing and Rehabilitation Center.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Routine
Census: 93
Deficiencies: 3
Date: Oct 8, 2023
Visit Reason
A standard survey was conducted at Comfort Creek Nursing and Rehabilitation from October 6, 2023, through October 8, 2023 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including unsafe and unsanitary environmental conditions, failure to complete required PASARR Level II assessments for certain residents, and failure to properly assess and monitor skin conditions for a resident.
Deficiencies (3)
Facility failed to maintain a safe, clean, and home-like environment with floors and room doors scuffed and dirty in multiple rooms on D and E halls.
Facility failed to complete new PASARR Level II assessments after admission for four residents with qualifying psychological diagnoses.
Facility failed to provide treatment and care in accordance with professional standards for one resident by failing to assess and monitor bruises and follow physician orders related to weekly skin audits.
Report Facts
Resident census: 93
Rooms with environmental concerns: 9
Residents reviewed with PASARR issues: 4
Sampled residents for quality of care: 32
Skin audits documented: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA GG | Certified Nursing Assistant | Mentioned in relation to resident R244's bruises and care |
| CNA BB | Certified Nursing Assistant | Mentioned in relation to reporting bruises and open skin areas for resident R244 |
| LPN FF | Licensed Practical Nurse | Mentioned in relation to reporting skin condition observations for resident R244 |
| Treatment Nurse EE | Treatment Nurse | Mentioned in relation to skin audit documentation and assessments |
| Treatment Nurse DD | Treatment Nurse | Mentioned in relation to skin audit documentation and assessments |
| Administrator | Mentioned in relation to environmental issues and PASARR process | |
| Director of Nursing | DON | Mentioned in relation to PASARR process and skin audit deficiencies |
| Admissions Director | Mentioned in relation to PASARR process and training | |
| Maintenance Director | Mentioned in relation to environmental maintenance and repairs |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 8, 2023
Visit Reason
A State Licensure survey was conducted at Comfort Creek Nursing and Rehabilitation Center from October 6, 2023 through October 8, 2023 to assess compliance with state health regulations.
Findings
The facility failed to maintain a safe, clean, and home-like environment in multiple resident rooms on D and E halls, with issues including scuffed floors, dark streaks, chipped paint, torn furniture, and dirty bathroom areas. Environmental deficiencies were verified by the Administrator during room rounds.
Deficiencies (1)
Failure to ensure a safe, clean, and home-like environment in six of ten rooms on E hall and three of eight rooms on D hall, including scuffed floors, dark streaks, chipped paint, torn cushions, and dirty bathroom areas.
Report Facts
Rooms with environmental issues: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Interviewed regarding environmental maintenance and repair activities. |
| Administrator | Administrator | Verified environmental deficiencies and discussed ongoing Performance Improvement Plan. |
Inspection Report
Life Safety
Census: 94
Capacity: 98
Deficiencies: 3
Date: Oct 7, 2023
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to have a self-closing device on the mechanical room door, failure to red mark and lock out the fire alarm electrical circuit, and multiple penetrations above the ceiling through the one-hour fire and smoke barrier. These deficiencies could place residents at risk in the event of fire or smoke migration.
Deficiencies (3)
Failed to apply a self-closing device to the mechanical room door in hallway B, risking fire and smoke migration affecting patient evacuation.
Failed to red mark and lock-out the fire alarm electrical circuit, risking accidental deactivation and loss of early fire warning.
Multiple penetrations above the ceiling through the one-hour fire and smoke barrier at Hallway A, risking smoke migration between compartments.
Report Facts
Census: 94
Total Capacity: 98
Residents at risk due to mechanical room door deficiency: 30
Residents at risk due to fire alarm circuit deficiency: 98
Residents at risk due to smoke barrier penetrations: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M interviewed and confirmed findings during the inspection |
Inspection Report
Deficiencies: 3
Date: Oct 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to environmental conditions, pre-admission screening and resident review (PASRR) processes, and treatment and care practices in the nursing facility.
Findings
The facility failed to maintain a safe, clean, and homelike environment in multiple resident rooms, failed to complete required PASRR Level II assessments for several residents with qualifying psychological diagnoses, and failed to properly assess and monitor skin conditions for one resident, including incomplete documentation of weekly skin audits.
Deficiencies (3)
F 0584: The facility failed to maintain a safe, clean, and homelike environment in six of 10 rooms on E hall and three of eight rooms on D hall, with floors and doors scuffed and dirty, chipped paint, and peeling surfaces.
F 0644: The facility failed to complete new PASRR Level II assessments after admission for four residents with qualifying psychological diagnoses, potentially affecting their care planning and services.
F 0684: The facility failed to provide appropriate treatment and care for one resident by not assessing and monitoring bruises on bilateral arms and failing to follow physician orders for weekly skin audits, with incomplete documentation and lack of awareness by treatment nurses.
Report Facts
Rooms with environmental issues: 9
Residents affected by PASRR deficiency: 4
Sampled residents: 32
Skin audits documented: 5
Inspection Report
Deficiencies: 0
Date: May 26, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Comfort Creek Nursing and Rehabilitation Center following a regulatory survey.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Date: May 26, 2023
Visit Reason
A second revisit survey was conducted to verify correction of deficiencies cited in the previous 4/6/23 revisit survey.
Findings
All deficiencies cited as a result of the 4/6/23 revisit survey were found to be corrected.
Inspection Report
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Comfort Creek Nursing and Rehabilitation Center following a survey completed on April 6, 2023.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 1
Date: Apr 6, 2023
Visit Reason
A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid regulations following a prior survey.
Findings
The facility failed to ensure proper respiratory services for two residents with tracheostomies by not having one size smaller tracheostomy tubes at the bedside and not performing tracheostomy tube changes as recommended, increasing risk of respiratory distress.
Deficiencies (1)
Failed to include one size smaller tracheostomy tube in emergency supplies at bedside and failed to ensure tracheostomy tube changes were performed as recommended for two residents.
Report Facts
Census: 90
BIMS score: 99
MDS assessment date: Jan 4, 2023
MDS assessment date: Feb 8, 2023
Last documented trach change date: Apr 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Interviewed about tracheostomy care training and emergency procedures |
| LPN AA | Licensed Practical Nurse | Interviewed about tracheostomy care education and emergency procedures |
| LPN EE | Licensed Practical Nurse | Interviewed about recent education on trach care and emergency trach care |
| LPN FF | Licensed Practical Nurse | Interviewed about education on trach care, suctioning, and emergency care |
| Director of Nursing | Director of Nursing | Interviewed about supply stocking and nursing staff competencies |
| Administrator | Facility Administrator | Interviewed about tracheostomy tube replacement policies and emergency procedures |
| Respiratory Therapist | Respiratory Therapist | Provided training to staff on trach care and routine trach changes |
| ENT PC | Ear Nose Throat Physician | Provided information about Resident #7's status and appointment |
| Ear Nose Throat Allergy Physician | ENT Physician | Provided information about Resident #63's trach change schedule and history |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Routine
Deficiencies: 15
Date: Feb 2, 2023
Visit Reason
Routine inspection of Comfort Creek Nursing and Rehabilitation Center to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident abuse prevention, care planning, respiratory care, medication security, dietary services, staffing, immunizations, COVID-19 vaccination compliance, and maintenance. Several residents experienced inadequate care plans, lack of emergency tracheostomy supplies, unsecured medications, insufficient dietary staffing and sanitation, incomplete pneumococcal vaccinations, and delayed maintenance repairs.
Deficiencies (15)
F0600: The facility failed to prevent resident-to-resident physical abuse for two residents, R#47 and R#88, resulting in minimal harm or potential for harm.
F0609: The facility failed to timely report suspected staff-to-resident verbal abuse for one resident, R#238, to the State Survey Agency and law enforcement.
F0610: The facility failed to suspend a staff member pending investigation of verbal abuse allegations toward resident R#238, risking continued abuse.
F0655: The facility failed to develop and implement a baseline care plan within 48 hours of admission for resident R#237, risking unmet immediate care needs.
F0656: The facility failed to develop and implement complete care plans with emergency tracheostomy interventions for residents R#7 and R#63, increasing risk of respiratory distress.
F0688: The facility failed to provide appropriate range-of-motion and splinting services for four residents (R#63, R#6, R#4, R#7), risking worsening contractures.
F0689: The facility failed to provide adequate supervision to prevent elopement for resident R#62, who exited the facility unsupervised.
F0695: The facility failed to maintain emergency tracheostomy supplies at the bedside and ensure respiratory equipment was clean for residents R#7, R#63, R#46, and R#80.
F0761: The facility failed to secure medications properly; one medication cart was unlocked and unattended, and resident R#80 had unsecured medication vials at bedside.
F0802: The facility failed to maintain sufficient dietary staffing, resulting in unsanitary food preparation areas, unclean equipment, and incomplete cleaning schedules.
F0812: The facility failed to store, prepare, and serve food in a sanitary manner; food preparation surfaces and equipment were unclean, foods were unlabeled and unsealed, and scoops were improperly stored.
F0841: The facility failed to ensure the Medical Director was involved in policy development and staff education related to emergency tracheostomy care and pneumococcal vaccination.
F0883: The facility failed to update pneumococcal vaccination policy per current CDC guidelines and failed to ensure four residents received appropriate pneumococcal vaccinations or documented refusals.
F0888: The facility failed to ensure all staff were vaccinated for COVID-19 or tested twice weekly as required; one staff member had an invalid medical exemption and nine unvaccinated/exempt staff were not tested twice weekly.
F0921: The facility failed to maintain a bathroom sink in working order for resident R#47; the sink was stopped up for months and not repaired timely.
Report Facts
Unvaccinated staff: 10
Unvaccinated staff tested twice weekly: 1
Days without RN coverage: 15
Residents under age threshold: 39
Dietary staffing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Had a medical exemption for COVID-19 vaccine without valid contraindication |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Confirmed resident abuse and exit incident |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing, medication cart security, and care plan responsibilities |
| Dietary Manager | Dietary Manager | Reported dietary staffing shortages and incomplete cleaning |
| Medical Director | Medical Director | Interviewed regarding tracheostomy care and vaccination policies |
| Restorative Aide 1 | Restorative Aide | Interviewed about splinting and restorative care |
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 7
Date: Feb 2, 2023
Visit Reason
The inspection was a State Licensure survey conducted from January 30, 2023 through February 2, 2023 to determine compliance with State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including failure to suspend a staff member pending abuse investigation, inadequate RN coverage, unsecured medications, failure to provide range-of-motion and splinting services, inadequate supervision to prevent elopement, unsanitary kitchen conditions, and failure to update and properly administer pneumococcal vaccinations.
Deficiencies (7)
Failure to suspend a staff member pending investigation into verbal abuse allegation towards a resident.
Failure to ensure required RN coverage of at least eight consecutive hours per day, seven days per week.
Medication carts not locked at all times; unsecured medications found at bedside.
Failure to provide range-of-motion and/or splinting services for residents with contractures.
Failure to provide supervision to prevent elopement of a resident at risk.
Unsanitary kitchen conditions including unclean food preparation surfaces, equipment, utensils, and improperly stored foods.
Pneumococcal vaccination policy not updated to reflect current CDC recommendations; failure to ensure four of five residents received pneumococcal vaccination or documented refusals.
Report Facts
Residents reviewed for abuse: 11
Facility census: 87
Residents sampled for medication cart security: 33
Residents reviewed for range of motion: 6
Residents reviewed for elopement risk: 8
Residents under age 65: 39
Residents reviewed for pneumococcal vaccination: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | LPN, Unit Manager | Named in verbal abuse allegation investigation and elopement incident |
| Licensed Practical Nurse 5 | LPN | Named in medication cart locking deficiency |
| Director of Nursing | DON | Named in RN coverage and medication cart deficiencies |
| Regional Vice President of Operations | RVPO | Interviewed regarding abuse investigation and pneumococcal vaccination policy |
| Regional Nurse Consultant | Nurse Consultant | Interviewed regarding pneumococcal vaccination policy |
| Medical Director | Medical Director | Interviewed regarding pneumococcal vaccination policy |
| Dietary Manager | DM | Named in kitchen sanitation deficiencies |
| Dietary Aide 1 | DA1 | Named in food temperature monitoring deficiency |
| Licensed Practical Nurse 1 | LPN1 | Named in splinting care deficiency for resident R#7 |
| Certified Nursing Assistant 3 | CNA3 | Named in splinting care deficiency for resident R#7 |
| Restorative Aide 1 | RA1 | Named in splinting care deficiency for resident R#7 |
Inspection Report
Routine
Census: 87
Deficiencies: 16
Date: Feb 2, 2023
Visit Reason
A standard survey was conducted at Comfort Creek Nursing and Rehabilitation Center from January 30, 2023, through February 2, 2023, including complaint investigations of multiple complaint intake numbers.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with deficiencies related to resident abuse, failure to report verbal abuse, incomplete baseline care plans, inadequate care plan interventions for tracheostomy care, failure to provide restorative nursing services, inadequate supervision of an elopement risk resident, respiratory care deficiencies, failure to provide meals for dialysis residents, insufficient RN coverage, unsecured medication carts and medications, unsanitary dietary conditions, lack of Medical Director involvement in key policies, incomplete pneumococcal vaccination policy and practice, incomplete COVID-19 vaccination compliance, and unresolved maintenance issues.
Deficiencies (16)
Failure to ensure residents were free from physical abuse by another resident.
Failure to implement policies and procedures for reporting reasonable suspicion of a crime and failure to report verbal abuse to the State Survey Agency.
Failure to suspend staff pending investigation of verbal abuse allegation.
Failure to develop and implement a baseline care plan within 48 hours of admission.
Failure to ensure care plan interventions related to emergency tracheostomy care were developed and accurate.
Failure to provide range-of-motion and/or splinting services to address contractures for residents with limited range of motion.
Failure to provide supervision to prevent elopement for a resident at risk.
Failure to ensure provision of respiratory services in accordance with professional standards including emergency tracheostomy supplies and equipment maintenance.
Failure to make arrangements for provision of meals for a resident receiving dialysis when out of the facility.
Failure to ensure required RN coverage of at least eight consecutive hours per day, seven days per week.
Failure to ensure medication carts were locked at all times and medications were secured.
Failure to store, prepare, and serve foods in a sanitary and safe manner; failure to complete routine cleaning schedules; failure to maintain food temperatures.
Failure to ensure Medical Director involvement in administrative decisions including policy development and approval related to pneumococcal vaccination and emergency tracheostomy care.
Failure to update pneumococcal vaccination policy to reflect current recommendations and failure to ensure residents received appropriate pneumococcal vaccination or documented refusals.
Failure to meet COVID-19 vaccination compliance requirements and failure to ensure unvaccinated exempt staff were tested twice weekly.
Failure to ensure maintenance work requests were completed timely resulting in a stopped up bathroom sink for over two months.
Report Facts
Resident census: 87
Unvaccinated staff: 10
Staff not tested twice weekly: 9
Days without RN coverage: 15
Residents under age 65: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 6 | Licensed Practical Nurse | Had a medical exemption for COVID-19 vaccination without valid contraindication |
| LPN 4 | Licensed Practical Nurse | Confirmed resident elopement and discussed tracheostomy emergency equipment |
| LPN 5 | Licensed Practical Nurse | Left medication cart unlocked at nurse's station |
| Director of Nursing | Director of Nursing | Scheduled as RN despite census prohibiting DON as charge nurse; confirmed medication cart policy |
| Dietary Manager | Dietary Manager | Reported dietary understaffing and incomplete cleaning schedules |
| Medical Director | Medical Director | Not involved in policy updates or education for tracheostomy care and pneumococcal vaccination |
| Regional Nurse Consultant | Regional Nurse Consultant | Discussed tracheostomy care policy and pneumococcal vaccination recommendations |
| Infection Preventionist | Infection Preventionist | Provided vaccination exemption records and discussed COVID-19 testing protocol |
Inspection Report
Life Safety
Census: 88
Capacity: 98
Deficiencies: 9
Date: Jan 30, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, with multiple deficiencies observed including failure to repair emergency lighting, maintain sprinkler system components, maintain clearance to fire extinguishers, cover exposed wiring, and properly install electrical components.
Deficiencies (9)
Failed to repair emergency light in A hall.
Failed to replace rusted escutcheon ring in A hall solid utility room.
Failed to remove wires supported by sprinkler piping throughout A, B, C, D, E halls.
Failed to change painted sprinkler head in kitchen above sink.
Failed to maintain clearance to fire extinguisher blocked by patient lift and wheelchair in A hall.
Failed to properly cover exposed wires in A hall.
Failed to replace broken receptacle cover in Room A3 and missing switch cover in B hall corridor end.
Failed to cover open junction box above ceiling in B hall.
Failed to properly install power strip on floor in B hall nursing room.
Report Facts
Certified beds: 98
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
Inspection Report
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Comfort Creek Nursing and Rehabilitation Center following a survey completed on July 21, 2021.
Findings
The report contains initial comments but does not provide specific details about deficiencies or findings.
Inspection Report
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Comfort Creek Nursing and Rehabilitation Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 78
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the Recertification Survey conducted on 2021-05-13 and the Complaint Survey conducted on 2021-04-30.
Findings
All deficiencies cited in the prior Recertification and Complaint Surveys were found to be corrected during this revisit survey.
Report Facts
Census: 78
Inspection Report
Re-Inspection
Census: 78
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Complaint Survey conducted on 2021-04-30.
Complaint Details
The revisit survey was conducted following a Complaint Survey on 2021-04-30; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the Complaint Survey were found to be corrected during this revisit survey.
Report Facts
Census: 78
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 6
Date: May 13, 2021
Visit Reason
A licensure survey was conducted from May 10, 2021 through May 13, 2021 to assess compliance with Long Term Care Facilities regulations.
Findings
The facility was found not in substantial compliance with multiple deficiencies including failure to maintain resident privacy, improper use of antipsychotic medications, inadequate assistance with activities of daily living, infection control lapses related to COVID-19 protocols, environmental sanitation issues, and lack of adequate recreational programming for residents.
Deficiencies (6)
Failure to maintain visual privacy for one resident during care.
Use of duplicate antipsychotic medications without adequate indication or gradual dose reduction.
Failure to provide nail care for one resident, increasing risk of infection.
Failure to implement infection prevention and control program including hand hygiene, social distancing, PPE use, and isolation protocols for COVID-19.
Failure to follow proper environmental sanitation procedures including disinfectant dwell time and cross contamination prevention.
Failure to provide ongoing recreational activities for a cognitively impaired resident, leading to potential boredom and depression.
Report Facts
Residents observed in dining room: 22
Residents observed in dining room: 14
Wandering behaviors: 25
Opportunities for wandering behavior: 62
Facility census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD1 | Physician | Discussed antipsychotic medication management for Resident 33. |
| CNA5 | Certified Nurse Aide | Observed providing incontinence care without maintaining privacy for Resident 19. |
| CNA6 | Certified Nurse Aide | Reported on Resident 33's behavior and activity level. |
| LPNM1 | Licensed Practical Nurse Manager | Provided information on Resident 33's behavior and medication. |
| RN1 | Registered Nurse | Observed and commented on infection control practices and social distancing. |
| HSK1 | Housekeeper | Observed failing to follow proper cleaning and disinfecting procedures. |
| HSK2 | Housekeeper | Observed failing to follow proper cleaning and disinfecting procedures. |
| HSK3 | Housekeeper | Observed cleaning a resident's room without proper PPE. |
| HSKD | Housekeeping Director | Interviewed about housekeeping training and cleaning procedures. |
| AD | Activity Director | Reported on lack of activity programming for Resident 33. |
| CNA7 | Certified Nursing Aide | Unaware of Resident 42's nail care needs. |
| LPN5 | Licensed Practical Nurse | Discussed quarantine and mask use for Resident 280. |
| LPN6 | Licensed Practical Nurse | Observed not redirecting Resident 280 to wear mask properly. |
| COTA1 | Certified Occupational Therapy Assistant | Entered PUI resident's room without proper PPE. |
Inspection Report
Routine
Census: 81
Deficiencies: 9
Date: May 13, 2021
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations and long term care facility requirements.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident privacy, abuse prevention, ADL care, activity programming, range of motion maintenance, psychotropic medication use, medication security, menu adherence, and infection control practices.
Deficiencies (9)
Failure to maintain visual privacy for a non-verbal resident during incontinence care.
Failure to suspend a staff member pending investigation of abuse allegations.
Failure to provide nail care for a resident, increasing risk of infection.
Failure to provide ongoing activity programming for a resident with severe cognitive impairment.
Failure to ensure splint use for a resident with contracted hand, risking decreased range of motion.
Use of duplicate antipsychotic medications without adequate indication or gradual dose reduction.
Failure to secure multiple medications on nurses' station and expired glucose control solution not removed timely.
Failure to follow approved menus for pureed and mechanical soft diets, omitting foods and substitutions without dietitian approval.
Failure to implement infection prevention and control program including hand hygiene, mask use, social distancing, PPE use for PUI residents, and proper environmental cleaning.
Report Facts
Resident census: 81
Residents on pureed diet: 5
Residents on mechanical soft diet: 12
Residents receiving meals from kitchen: 78
Residents observed in dining room: 22
Residents observed in dining room: 14
Residents served by CNA4: 11
Residents on psychotropic medications: 1
Wandering behaviors documented: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 5 | CNA | Named in privacy deficiency for failure to provide visual privacy during care |
| Certified Nursing Aide 1 | CNA | Named in abuse allegation investigation and failure to suspend pending investigation |
| Licensed Practical Nurse Manager 1 | LPNM | Involved in abuse investigation and medication administration oversight |
| Registered Nurse 1 | RN | Interviewed regarding nail care and infection control |
| Certified Nursing Aide 7 | CNA | Interviewed regarding nail care deficiency |
| Activity Director | AD | Interviewed regarding activity programming deficiency and hand hygiene |
| Cook 1 | Cook | Interviewed regarding menu substitutions and food preparation |
| Housekeeper 1 | HSK | Observed and interviewed regarding infection control and cleaning practices |
| Housekeeper 2 | HSK | Observed and interviewed regarding infection control and cleaning practices |
| Housekeeper 3 | HSK | Observed and interviewed regarding infection control and cleaning practices |
| Housekeeping Director | HSKD | Interviewed regarding housekeeping infection control practices |
| Administrator | Administrator/Infection Control Preventionist | Interviewed regarding infection control program and deficiencies |
| Licensed Practical Nurse 5 | LPN | Observed and interviewed regarding resident mask use and quarantine |
| Licensed Practical Nurse 6 | LPN | Observed regarding resident mask use and quarantine |
| Certified Occupational Therapy Assistant 1 | COTA | Observed and interviewed regarding PPE use in PUI resident room |
| Licensed Practical Nurse 4 | LPN | Interviewed regarding splint use for resident |
| Medical Doctor 1 | MD | Interviewed regarding psychotropic medication use and dose reduction |
Inspection Report
Life Safety
Census: 81
Capacity: 98
Deficiencies: 0
Date: May 11, 2021
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Report Facts
Certified beds: 98
Census: 81
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 30, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00213954.
Complaint Details
Complaint GA00213954 was substantiated with no State deficiencies written.
Findings
The complaint GA00213954 was substantiated but no State deficiencies were written.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 30, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00213954, which was substantiated with deficiencies related to nutrition and hydration status maintenance.
Complaint Details
Complaint GA00213954 was substantiated with deficiencies related to nutrition and hydration status maintenance.
Findings
The facility failed to identify severe weight loss in a timely manner for three residents dependent on gastrostomy tube feeding due to inaccurate weight measurements. Weight discrepancies were discovered, affecting multiple residents, and staff interviews revealed issues with scale calibration and weight recording procedures.
Deficiencies (1)
Failure to identify weight loss to meet nutritional needs in a timely manner for three residents dependent on gastrostomy tube feeding related to inaccurate weights.
Report Facts
Severe weight loss: 19.8
Severe weight loss: 13.3
Severe weight loss: 6.2
Residents with weight loss identified after reweighing: 26
Weight loss in pounds: 34
Weight loss in pounds: 20.4
Weight loss in pounds: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN GG | Licensed Practical Nurse | Responsible for weight program and identified weight discrepancies |
| LPN EE | Licensed Practical Nurse | Wound care nurse who assisted in identifying weight discrepancies |
| RD | Registered Dietitian | Provided dietary assessments and noted weight discrepancies |
| Director of Nursing | Reported on weight discrepancy identification and system issues | |
| Administrator | Reported facility system was not working properly and interventions were put in place |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 8, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00212960.
Complaint Details
Complaint #GA00212960 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 76
Deficiencies: 0
Date: Sep 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 11, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00202872 and #GA00207753.
Complaint Details
Complaints #GA00202872 and #GA00207753 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00202872 and #GA00207753 were unsubstantiated and no regulatory violations were cited.
Inspection Report
Routine
Census: 76
Deficiencies: 0
Date: Aug 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices for COVID-19.
Inspection Report
Routine
Census: 85
Deficiencies: 0
Date: Jul 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 19, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00194096.
Complaint Details
Complaint GA00194096 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 8, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate allegations of poor quality of care and resident rights violations.
Complaint Details
The investigation was complaint-related, but the allegations were unsubstantiated.
Findings
The allegations of poor quality of care and resident rights violations were found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 25, 2018
Visit Reason
A revisit to the Standard Survey of August 23, 2018 was conducted to verify correction of previously cited deficiencies.
Findings
It was determined that the deficiencies cited during the Standard Survey had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 9, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Life Safety
Census: 92
Capacity: 98
Deficiencies: 3
Date: Aug 22, 2018
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain staff access to keys for exterior gates in egress paths, lack of NO EXIT signage on certain doors, and failure to maintain smoking regulations, all of which could place residents and staff at risk in the event of fire.
Deficiencies (3)
Facility failed to maintain staffing with keys to exterior gates in path of egress.
Facility failed to maintain NO EXIT signs on doors, including employee entry/exit door and gazebo entry/exit door.
Facility failed to maintain smoking regulations, evidenced by discarded cigarettes on grounds despite presence of fire proof cans.
Report Facts
Census: 92
Total Capacity: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to key access, NO EXIT signage, and smoking policy violations during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 28, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00186469.
Complaint Details
Complaint #GA00186469 was investigated and found to be unsubstantiated.
Findings
The complaint investigation was concluded as unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 11, 2018
Visit Reason
A complaint survey was conducted to investigate complaints (GA 00183860) by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint survey conducted for complaint GA 00183860; no deficiencies were found.
Findings
No deficiency was cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 18, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00181578 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00181578 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 18, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 17, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00180849 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint #GA00180849 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 10/16/17 through 10/17/17.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 10, 2017
Visit Reason
A follow-up to the Recertification survey of August 24, 2017, was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of October 6, 2017.
Inspection Report
Life Safety
Census: 92
Capacity: 98
Deficiencies: 6
Date: Aug 22, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain emergency lighting, smoke detectors, sprinkler system components, fire walls, removal of flex cords, and smoking regulations such as posting 'NO SMOKING' signs.
Deficiencies (6)
Failed to maintain emergency lighting; half of the emergency light at A hall egress doors was not working properly.
Failed to maintain smoke detectors; smoke detectors in air stream near therapy room and A hall fire doors were not maintained.
Failed to maintain sprinkler system and components; sprinkler head outside time clock room was heavily loaded.
Failed to maintain fire walls; fire walls not sealed with required materials, open penetrations in C and E hall fire walls, and fire walls not sealed to deck.
Failed to remove flex cords from use; a flex cord was modified and used as permanent wiring in the kitchen above the freezer.
Failed to maintain smoking policies; 'NO SMOKING' signs were not present on any entry/exit doors into the facility.
Report Facts
Residents at risk: 92
Certified beds: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the facility tour and observations. |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Jul 11, 2017
Visit Reason
A complaint survey was conducted at Vero Nursing and Rehab on July 11, 2017, related to complaint #GA00177116.
Complaint Details
Complaint #GA00177116 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint survey was unsubstantiated with no deficiencies found at the facility.
Report Facts
Complaint number: Complaint #GA00177116
Census: 92
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 4, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaints GA00173262, GA00160445, and GA00160119.
Complaint Details
Investigation of complaints GA00173262, GA00160445, and GA00160119; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
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