Failure to Accurately Include Comfort Care Population in Facility Assessment
Penalty
Summary
The facility failed to ensure its Facility Assessment included an accurate and comprehensive review of the resident population by omitting an identified group of residents receiving Comfort Care. The Facility Assessment for 2025–2026, dated 10/08/25 through 10/29/25, did not indicate or recognize a Comfort Care population and instead only identified residents on Hospice and Palliative Care services. Facility documentation showed that 10 residents, approximately 9.3% of the facility population, were receiving Comfort Care, while only two residents, approximately 1.9% of the population, were identified as receiving Hospice services. The Comfort Care population was therefore not reflected in the current Facility Assessment. During interviews, the DON and Administrator confirmed that the facility used the terms Palliative and Comfort Care interchangeably and that residents on Comfort Care were tracked via an Order Listing Report that documented residents with a “Palliative Care-Form on File.” The Administrator stated that a Comfort Care/Palliative Care Assessment was used in the nursing home setting like a wish list advanced directive to document care preferences, and acknowledged that the Facility Assessment used the term Palliative but not Comfort Care. The Administrator also stated that she had been told Palliative and Comfort Care were the same thing. As a result, the Facility Assessment did not distinguish or address unique and distinctive characteristics and care needs between residents receiving Comfort Care and those receiving Palliative Care, contributing to the cited deficiency under F684 Quality of Care.
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