Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Comfort Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Unclean kitchen equipment and improper food storage were observed in the facility. The can opener, stock pot, microwave, and food prep pans were stored with soil and/or moisture, and opened dry goods were left uncovered and undated. An opened container of thickened tea in a refrigerator was undated, and an opened container of thickened apple juice in a resident refrigerator was undated with an expired best if used by date.
The facility failed to determine a root cause for a resident with Alzheimer’s disease who eloped from the building twice and for another resident with dementia who repeatedly wandered into other residents’ rooms. Records showed both residents had wandering or elopement risk care plans, but staff observations and interviews confirmed the behaviors continued, including one resident entering another resident’s room, touching a medication cart, and needing redirection. The DON/administrator acknowledged no root cause analysis was completed for the elopements and no documentation addressed the room-entry behavior.
Failure to Provide Requested Bathing Care: Two cognitively intact, dependent residents with ADL assistance needs did not receive showers reflected in their care preferences and Kardex documentation. One resident with stiff person syndrome reported no shower since February and wanted one, while another resident with quadriplegia reported his last shower was months earlier; both had bathing marked as important, no refusals documented, and facility staff confirmed no shower log and no showers recorded in the past 30 days.
Unsecured prescription topical medications were found in a resident’s room even though the resident was not self-administering them. The resident had quadriplegia, was cognitively intact, and required staff assistance for care; records showed only one shampoo was authorized to be kept at bedside, while the hydrocortisone cream had no bedside authorization. During observation, boxed tubes of hydrocortisone were left on a water dispenser and the shampoo was kept in the bathroom, while the resident stated nursing staff applied both medications.
A resident dining area was observed with five chairs that had tears in the seat surfaces while residents were eating at the tables. The DON confirmed the chairs had exposed non-cleanable material and that the tears made the seats uncleanable.
Inaccurate MDS Coding for Side Rail Use: A resident with Alzheimer's disease and cognitive communication deficit had a quarterly MDS that incorrectly coded daily side rail use and restraint use. Observations showed the resident in bed without side rails or restraints, and both an LPN and the MDSC confirmed the resident had never used bedside rails or any physical restraints. The Administrator also acknowledged the MDS was inaccurate.
Care plan not updated for a resident with dementia and severe cognitive impairment who was identified as wandering and exit-seeking. Staff observed the resident wandering the halls, touching the med cart, and entering other residents’ rooms, while interviews confirmed this happened often. The care plan addressed location checks but did not include interventions for entering other residents’ rooms.
A resident with ESRD and severely impaired cognition was sent to dialysis on a regular schedule, but the facility did not complete or send the required dialysis communication sheet. Staff stated they only documented pre- and post-dialysis evaluations in progress notes and did not use dialysis communication forms, while the dialysis charge nurse said the form was required to communicate baseline status, changes of condition, and new MD orders. The facility policy required the dialysis communication record to accompany the resident to dialysis.
Failure to prime an insulin pen before administration. An LPN checked a resident’s BG, determined 10 units of NovoLog were needed, and prepared the insulin pen for injection without priming the disposable needle. The LPN stated she had never been told how to prime the pen, and the DON said she was unaware of the need to prime it. The manufacturer’s instructions required priming with a 2-unit dose before giving the ordered dose.
The facility failed to notify a resident’s responsible party of the resident’s discharge and transfer to a personal care home, despite facility policy requiring family involvement in discharge planning. The resident, who had severe cognitive impairment per BIMS scores and diagnoses including schizophrenia, schizoaffective disorder, intellectual disabilities, and major depressive disorder, had a care plan stating that he and his family wished for discharge to a facility closer to them. Although the RP had been consistently notified in the past for consents and changes in care, there was no documentation of RP notification for the discharge. The SSD stated she was unaware she needed to notify the RP, the DON confirmed the family was not notified and should have been, the Administrator acknowledged knowing of the discharge and assuming the SSD had notified the RP, and the NP stated she was unaware the family had not been involved and that the RP should have been notified given the resident’s BIMS score.
A resident with severe cognitive impairment and traumatic brain injury was found unresponsive and CPR was initiated. Despite facility policy requiring prompt notification, the family and physician were not informed of the change in condition or emergency interventions until after the resident was pronounced deceased. Staff interviews confirmed the delay in notification, and the family expressed distress over not being notified sooner.
Two residents with behavioral health diagnoses and a history of aggression engaged in a verbal and physical altercation, resulting in a minor injury. Despite care plans identifying aggression risks and facility policy requiring monitoring of provoking behaviors, staff did not prevent the incident, leading to a failure to protect residents from abuse.
A resident with moderate cognitive impairment and multiple psychiatric diagnoses was not invited to participate in their care conference, contrary to facility policy. Documentation showed only the resident's sister was included, and interviews with the resident and staff confirmed the resident was not invited or aware of the meeting.
A resident with a tracheostomy, who was care planned to perform self-care with staff observation and supply support, did not receive appropriate supervision or necessary supplies for tracheostomy care. The resident used non-sterile items like toilet paper and napkins due to lack of supplies, and staff did not directly observe or assist with care, instead relying on the resident's verbal confirmation. Nursing staff were unaware of the correct tracheostomy tube size and could not promptly locate supplies, resulting in the resident not receiving tracheostomy care as ordered.
A resident with a full code status was found unresponsive, and the facility failed to call 911 and continue CPR as required. Despite staff efforts to perform CPR, there was no documentation of EMS being contacted, and the Medical Director ordered CPR to stop after 20 minutes. The facility lacked an AED and proper hands-on CPR training, contributing to the deficiency.
A facility failed to follow proper CPR procedures for a resident with a resuscitation order, as staff did not contact EMS during the process. The incident involved an LPN who initiated CPR with other staff but did not document EMS notification, a critical step in the emergency response. The DON confirmed the oversight, and the Administrator was unsure of the CPR policy and AED availability.
Unclean equipment and improperly stored opened food items
Penalty
Summary
The facility failed to ensure kitchen food preparation and service equipment were clean and dry when stored. During the kitchen inspection, the large manual can opener had dried and sticky substances on its blade and base attachment, a stock pot stored and ready for use had dried food substances on its interior cooking surface, the microwave oven had dried food substances and splatters in its inner cooking compartment, and five food preparation pans stacked for use had moisture on them, with one pan also containing grits on its interior cooking surface. The Dietary Manager confirmed the equipment was stored unclean and/or wet and stated kitchen staff should make sure food preparation equipment was clean and dry prior to storing it for use. The facility also failed to properly store opened food items in the kitchen and resident refrigerators. In dry storage, one opened 56-ounce package of dried stuffing and two opened 16-ounce packages of dried alfredo sauce mix were stored open to air and unprotected from possible contamination. In a reach-in refrigerator, an opened 46-ounce container of thickened tea with lemon flavor did not have a date showing when it was opened. In the front hall pantry resident refrigerator, an opened and undated 46-ounce container of thickened apple juice had a best if used by date of 04/07/2026 that had expired. The Dietary Manager confirmed the undated and improperly stored items and stated staff should date food when opened, cover it completely when placing it into storage, and discard expired food or beverages.
Failure to Determine Root Cause for Elopement and Room Intrusion
Penalty
Summary
The facility failed to determine a root cause for two residents who were observed in unsafe wandering-related events. One resident with Alzheimer’s disease, auditory hallucinations, anxiety, and a documented history of wandering and elopement risk was found outside the building on two separate occasions. The record showed an elopement evaluation identifying the resident as an elopement risk, care plan interventions such as 15-minute checks and purposeful activities, and documentation that the resident was escorted back inside after each event. The administrator confirmed the resident eloped twice and that staff education, care plan review, and one-on-one observation were implemented, but also confirmed the facility did not perform a root cause analysis. The facility’s records also showed another resident with dementia, adjustment disorder with disturbance of conduct, and altered mental status who had a care plan for wandering/elopement risk with regular location checks during waking hours. During observation, this resident wandered the hallway and later entered two other residents’ room, where one resident yelled for him to leave. Staff did not check or monitor the resident’s location or respond to the yelling, and there was no sign on the door to deter entry. The resident was also observed touching the medication cart and had to be redirected back to his room. Interviews supported that the behavior was recurring. A CNA stated the resident went into other residents’ rooms often, especially the same two rooms, and a CMA stated staff usually caught him before he went in. One resident stated the individual entered his room repeatedly, and the administrator acknowledged there was no documentation that the resident was care planned for entering other residents’ rooms and that the behavior would be addressed as a new issue. Video footage reviewed by the administrator and maintenance director showed the resident entering the room of the two residents.
Failure to Provide Requested Bathing Care
Penalty
Summary
The facility failed to respect resident rights when it did not provide ADL care of the residents’ choice for two dependent residents, R15 and R16. The report states that the facility’s policy required residents to be bathed as needed, including sponge baths, bed baths, or showers at least twice weekly. R15 was admitted with stiff person syndrome, had a BIMS score of 15, was cognitively intact, and was assessed as totally dependent on staff with extensive assistance needed for bed mobility. Her MDS indicated bathing was somewhat important to her. Her care plan required assistance with self-care, but her Kardex for the past 30 days showed only bed baths and no showers, with no refusals documented. R15 stated she had not received a shower since February and said she would like one. R16 was admitted with quadriplegia and a cervical disorder, had a BIMS score of 15, was cognitively intact, and was assessed as requiring extensive assistance from two staff for bed mobility and being totally dependent on two staff for transfers. His MDS indicated bathing was very important to him. His care plan required assistance with bathing, but his Kardex for the past 30 days showed no showers, and no refusals were documented; the Kardex did show a bed bath. R16 stated the last time he received a shower was on 12/08/25. The Unit Manager confirmed showers were scheduled at least two days per week or more if needed, that there was no shower log, and that the Kardex did not show showers for either resident. The Administrator stated that all residents were to receive regular hygiene care.
Unsecured Medications Stored in Resident Room
Penalty
Summary
Drugs and biologicals were not stored in a secure manner for one resident who was not self-administering medications. The facility policy titled Medication Administration, dated 01/2025, stated residents may self-administer medications only after an assessment and that licensed nursing staff are responsible for maintaining medications in a secure area and ensuring safe medication management. Review of the resident’s record showed admission diagnoses including quadriplegia (C5-C7 incomplete) and a cervical disorder, with a BIMS score of 15 out of 15 and dependence on staff for bed mobility and transfers. The resident’s care plan allowed Ketoconazole shampoo to be kept at the bedside with staff responsible for application, but there was no documentation allowing Hydrocortisone 2.5% topical cream to be kept at bedside. Active orders included Hydrocortisone 2.5% topical cream every 12 hours and Ketoconazole shampoo kept at the bedside. During observation, two boxed and labeled tubes of Hydrocortisone topical cream were found unsecured on a water dispenser next to the resident’s bed, and the Ketoconazole shampoo was stored in the resident’s bathroom. The resident stated he was physically unable to apply the medications or wash his hair due to quadriplegia and confirmed nursing staff applied the creams and shampoo. The UM confirmed the Hydrocortisone cream was stored unsecured in the room, and the Administrator stated the resident was unable to self-administer topical medications and that medications were expected to be stored securely.
Dining Room Chairs Had Torn, Uncleanable Seats
Penalty
Summary
The facility failed to provide a safe and clean environment in the dining room by allowing dining room chairs to remain with tears in the seating surfaces. During an observation of residents eating at the dining room tables on 04/27/2026 at 12:15 PM, five dining room chairs were seen with tears in the seats. During an interview on 04/27/2026 at 11:45 AM, the DON confirmed the five chairs had tears in the seat with exposed non-cleanable material and stated the chairs must be cleanable, with the tears rendering the seats uncleanable.
Inaccurate MDS Coding for Side Rail Use
Penalty
Summary
The facility failed to ensure an accurate MDS assessment was submitted for the use of side rails for one resident with Alzheimer's disease and cognitive communication deficit. The resident was admitted to the facility with those diagnoses, and the quarterly MDS with an ARD of 03/19/2026 indicated the resident used side rails daily and had a BIMS score of 3 out of 15, showing severe cognitive impairment. However, observations of the resident on 04/27/2026, 04/28/2026, and 04/29/2026 showed the resident in bed without side rails or any physical restraints present. An LPN who frequently cared for the resident stated the resident had never used bedside rails or any physical restraints, and the MDSC confirmed the resident did not use side rails or restraints and that the quarterly MDS had been coded in error. The Administrator also confirmed the facility did not utilize physical restraints and that the MDS inaccurately reflected daily use of side rails.
Care Plan Not Updated for Wandering Resident Entering Other Residents’ Rooms
Penalty
Summary
The facility failed to ensure that one wandering resident’s care plan was developed and updated with appropriate interventions. The resident was admitted with dementia, adjustment disorder with disturbance of conduct, and altered mental status. The annual MDS showed a BIMS score of 99 out of 15, indicating severe cognitive impairment. The care plan dated 04/07/2026 identified the resident as at risk for wandering/elopement related to exit-seeking behaviors and included checking the resident’s location regularly during and between rounds during waking hours, but it did not address interventions for wandering into other residents’ rooms. Observations and staff interviews showed the resident wandering in the hallway, touching the medication cart, and entering other residents’ rooms. During one observation, the resident entered two residents’ room and was verbally redirected by one resident, while staff did not check or monitor the resident’s location or respond to the yelling. Staff interviews confirmed the resident frequently went into other residents’ rooms, especially those of two specific residents. The Administrator stated the resident was re-oriented back to his room and confirmed there was no documentation that he was care planned for entering other residents’ rooms.
Missing Dialysis Communication Records
Penalty
Summary
The facility failed to ensure that dialysis communication sheets were completed for one resident who required hemodialysis. The resident was admitted with end stage renal disease and had a quarterly MDS showing a BIMS score of 6 out of 15, indicating severely impaired cognitive function. The care plan included interventions for the resident to receive lunch in a proper storage container for dialysis days and to send communication forms with the resident to dialysis as indicated and follow up as needed. The physician's orders also directed that medications be scheduled according to the dialysis treatment schedule so prescribed medications were held, not scheduled before hemodialysis, or administered or sent with the resident at dialysis as appropriate. During interviews, an LPN stated the resident went to dialysis every Tuesday, Thursday, and Saturday and that the facility did not have a communication sheet sent to the dialysis clinic, using only pre- and post-dialysis evaluations documented in progress notes. The UM also stated the facility only completed pre- and post-dialysis evaluations and did not use or have dialysis communication sheets. In contrast, the dialysis charge nurse stated the dialysis center required a dialysis communication form and that this resident was the only one who did not consistently bring one, because it was needed to identify baseline status and communicate changes of condition or new physician orders. The facility policy titled Renal Dialysis Management required completion of the facility dialysis communication record when a resident was sent to renal dialysis and review of that record when the resident returned.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to follow the manufacturer’s instructions for administering insulin by pen for one resident, R55, who had an order for NovoLog insulin. During observation on 04/29/2026 at 4:30 PM, LPN 4 checked R55’s blood glucose for sliding scale insulin administration, determined that 10 units of NovoLog were required, obtained a NovoLog insulin pen, verified the order, set the pen to 10 units, and prepared to administer the dose. LPN 4 stated she had not primed the disposable needle attached to the insulin pen and said she had never been told how to prime the pen. The Administrator/DON stated on 04/29/26 at 4:35 PM that she was unaware of the need to prime the insulin pen. Review of the manufacturer’s instructions for use showed that after the disposable needle is attached, the pen must be primed by dialing and activating a two-unit dose to expel air from the needle before giving the ordered dose.
Failure to Notify Responsible Party of Discharge for Resident With Severe Cognitive Impairment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party (RP) of the resident’s discharge and transfer to a personal care home, despite facility policy requiring family involvement in discharge planning. The facility’s Discharge Plan/Transfers policy states that when discharge is anticipated, a post-discharge plan is to be developed with the assistance of the resident and family, including a description of resident and family preferences, specific post-discharge needs, preparation for discharge, and review of the plan with the resident and family 24 hours before discharge. The resident’s clinical profile identified his sister as the RP and financial power of attorney. The resident had been admitted in 2018 and was discharged to a personal care facility on 2/11/2026. MDS assessments documented BIMS scores of 07 and 05 on recent assessments, indicating severe cognitive impairment. The care plan documented that the resident and his family wished for him to be discharged to a facility closer to them, with interventions including establishing a discharge plan with the resident and family as needed. On the day of discharge, a progress note documented that the resident had a planned discharge to a personal care facility at his request, that he was ambulatory, continent, independent with ADLs, continued to experience paranoia, refused a physical exam, but stated he felt fine and was ready to go with no voiced concerns. Review of the record showed that throughout the stay the RP had been routinely notified and involved for consents and notifications, including psychoactive medication consent, bed hold notification, immunization consents, and care conference invitations. However, for the discharge itself, there was no documentation that the RP was notified or involved. In interviews, the SSD stated she believed the resident was alert and oriented and was unaware she needed to notify the RP of the discharge. The DON confirmed the resident was discharged without family notification and stated that for a resident with a BIMS score of 05 or 07, the family should be notified and involved. The Administrator acknowledged knowing about the discharge, did not notify the RP, and assumed the SSD had done so, and the NP stated she was not aware the family had not been notified and agreed that a BIMS score of 05 indicated severe cognitive impairment and that the RP should have been notified of the discharge.
Failure to Promptly Notify Family and Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide timely notification to a resident's family and physician following a significant change in the resident's condition. According to the facility's policy, when a resident experiences a change in condition, the physician and family or responsible party must be notified promptly. In this case, a resident with a diagnosis of diffuse traumatic brain injury, who was bedbound, non-communicative, and had severe cognitive impairment, was found unresponsive and not breathing late at night. CPR was initiated, and emergency medical services (EMS) were called. Despite these critical events, the family and physician were not notified immediately. Documentation and staff interviews revealed that after the resident was found unresponsive and CPR was started, multiple attempts were made to contact the Medical Director and Director of Nursing, but there was no immediate response. The resident was not pronounced deceased until several hours later, and only then was the family notified. Staff confirmed that the family was not informed of the change in condition or the initiation of CPR until after the resident was officially pronounced deceased. The facility's policy required prompt notification, but this was not followed. The family member interviewed expressed distress and confusion about not being informed sooner, learning of the resident's death only hours after the event. Staff interviews further confirmed that the family was not notified during the critical period when the resident was unresponsive and resuscitation efforts were underway. The delay in notification was attributed by staff to the fact that the resident had not yet been pronounced deceased, despite the clear change in condition and initiation of emergency interventions.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by an altercation between two residents with known behavioral issues. One resident, with a history of major depressive disorder, psychotic disorder, dementia, bipolar disorder, PTSD, paranoid schizophrenia, and anxiety disorder, was identified as having moderate cognitive impairment and a care plan noting behavior problems related to physical aggression. The other resident, diagnosed with muscle weakness and major depressive disorder, was cognitively intact. Both residents were documented as being both givers and receivers of physical aggression in their care plans. On the day of the incident, a verbal altercation escalated when one resident was waiting for the other to retrieve items from a breakfast cart. After an exchange of words, one resident struck the other, who then followed him to his room and threw water on him, leading to a physical fight. The incident resulted in a minor injury, specifically a skin tear on one resident's hand. Staff interviews confirmed that the altercation was provoked by verbal exchanges and that both residents had a history of aggressive interactions. The facility's policy required staff to monitor behaviors that could provoke reactions and to review resident-to-resident abuse as potential abuse situations. Despite being aware of one resident's history of altercations at another facility and the behavioral risks identified in both residents' care plans, the facility did not implement sufficient measures to prevent the altercation. The failure to adequately monitor and intervene placed residents at continued risk of harm.
Resident Not Invited to Care Conference
Penalty
Summary
The facility failed to ensure that a resident participated in their care conference, as required by facility policy and regulatory standards. According to the facility's RAI/Care Planning Management document, residents are to be personally invited to care conferences by the social services department on the morning of the meeting, and invitations are mailed to family or responsible parties one week prior. Record review for a resident with multiple psychiatric and cognitive diagnoses, including moderate cognitive impairment, showed that while the resident's sister was included in the baseline care plan meeting, there was no documentation that the resident was invited to participate. During interviews, the resident confirmed not being invited to a care plan meeting and was unaware of what a care plan meeting was. The DON stated that only the responsible party was invited and was unsure if residents were included, while the Administrator affirmed that residents should be invited and that meetings could be held in residents' rooms if needed. The lack of resident invitation to the care conference was confirmed through both documentation and interviews.
Failure to Provide Tracheostomy Care, Supervision, and Supplies
Penalty
Summary
A resident with a history of cervical disc disorder and traumatic amputation was admitted to the facility with a tracheostomy and was care planned to perform self-care of his tracheostomy site, with staff instructed to observe and ensure supplies were available. The resident was cognitively intact and had physician orders for daily and as-needed tracheostomy care, including changing the inner cannula, performing trach care every shift, suctioning as needed, and changing the tracheostomy tie weekly. Despite these orders and care plan instructions, the resident reported that staff did not check on him during tracheostomy care, and there were no tracheostomy care supplies or suction equipment available in his room as required. During interviews and observations, the resident stated he used non-sterile items such as toilet paper and napkins to clean and support his tracheostomy tube due to a lack of appropriate supplies. He also revealed that his inner cannula had not been changed or cleaned since admission, and possibly for over a year, and that he would clear blockages himself by removing the inner cannula and coughing out mucus. Staff interviews confirmed that nursing staff had not observed or performed tracheostomy care for the resident, and documentation of care was based on the resident's verbal confirmation rather than direct observation or assistance. Further investigation revealed that staff were unaware of the resident's tracheostomy tube size and were unable to promptly locate appropriate supplies in the supply room. The facility was undergoing a transition with no designated treatment nurse, and regular nursing staff were responsible for treatments. Despite care plan instructions and physician orders, there was a lack of supervision, observation, and provision of necessary supplies for the resident's tracheostomy care, resulting in the resident using inadequate materials and not receiving proper care as ordered.
Failure to Activate 911 and Continue CPR
Penalty
Summary
The facility failed to activate 911 and continue CPR for a resident who was found unresponsive and without vital signs. The resident, who had a diagnosis of chronic obstructive pulmonary disease with acute exacerbation, was admitted with a physician's order to attempt resuscitation in the event of no pulse and no breathing. Despite this, the facility staff did not call 911, and CPR was stopped following an order from the Medical Director after approximately 20 minutes of resuscitation efforts. Interviews with the staff involved revealed a lack of clarity and communication regarding the emergency response procedures. LPN AA, who initially found the resident unresponsive, did not ensure that 911 was called, assuming that RN CC had made the call. However, RN CC confirmed that she did not call EMS, and there was no documentation to indicate that EMS was contacted. The facility's policy required that CPR be continued until EMS arrived, but this was not adhered to, leading to the resident's death. Further interviews with the Director of Nursing and other staff members highlighted a lack of proper equipment and training. The facility did not have an AED or defibrillator, and the CPR training provided to staff was online without hands-on practice. This deficiency in emergency preparedness and response contributed to the failure to provide adequate life-saving measures for the resident.
Removal Plan
- Licensed Nurses LPN AA and RN CC failed to continue Cardiopulmonary resuscitation until 911 services were called on R1.
- Licensed Nurse LPN AA and RN CC received CPR certification to include continuing CPR until 911 services arrive.
- Senior President of Clinical Services reviewed the policy Emergency Response Management policies and procedures and concluded no revisions were made.
- The Medical Director was educated on the policy and procedure for the Emergency Response Management by the Administrator.
- The Regional Nurse Consultant educated Director of Nursing and Administrator on Emergency Response Management policy and procedure.
- Education for the Emergency Response Management policy and procedure was completed by Director of Nursing and/or licensed staff. 3 of 4 RNs, 16 of 17 LPNs, 40 of 44 CNAs, 9 of 9 Dietary Staff, 9 of 14 Therapy staff, 3 of 3 Maintenance Director, 1 of 1 Business office Manager, 1 of 1 Social Service Director, 1 of 1 Activities Director, 1 of 1 Director of Nursing, 1 of 1 Administrator, 7 of 11 Housekeeping, 1 of 1 Admission Director, and 1 of 1 Human Resource Director 86.20 % of education was completed for all staff.
- All staff not educated on Emergency Response Management will be in-serviced prior to working their next scheduled shift by the Administrator, Director of Nursing, and or Licensed Nurse. All new hires will be educated during their onboarding process.
- An Advance Directive audit was completed by the Social Service Director to include the Physician Orders for Life-Sustaining Treatment (POLST), physician order, and care plan is accurate. 58 Residents elected to receive Cardiopulmonary resuscitation, and 21 residents elected to be a Do Not Resuscitate status for a total of 79, with one resident currently in the hospital. The Administrator and/or Director of Nursing will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR) including weekends and holidays.
- 10 of 10 licensed staff received Cardiopulmonary Resuscitation Certification provider whose training includes hands-on practice and in person skills assessment. The additional 11 licensed nurses had CPR Certification prior to compliance date. The total of licensed nurses with CPR certification is 100%.
- The Regional Nurse Consultant and or Regional MDS Nurse reviewed 79 of 79 resident's records of the Advance Directive audit to ensure orders, POLST, and care plans are completed accurately in the resident record.
- The Administrator conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting which consists of the Medical Director, Regional President of Operations, Business Office Manager, Social Service Director, MOS nurse, Certified Nurse Assistant, and licensed nurse to review the results of the most recent survey outcomes. The IDT (interdisciplinary Team) will review daily during morning clinical meeting to ensure compliance with following the Clinical Emergency Response Policy to include notifying 911 during CPR, auditing Advance Directives, Physician orders, and Care Plans.
Failure to Notify EMS During CPR
Penalty
Summary
The facility failed to ensure that staff followed appropriate procedures when providing Cardiopulmonary Resuscitation (CPR) for a resident who was reviewed for code status. The deficiency was identified when a resident, who had a physician's order to attempt resuscitation, was found unresponsive and without vital signs. The staff initiated CPR but failed to contact Emergency Medical Services (EMS) as required by the facility's Clinical Emergency Response Policy. The incident involved a Licensed Practical Nurse (LPN) who, upon finding the resident unresponsive, paged a code and returned with additional nursing staff to initiate CPR. Despite the ongoing resuscitation efforts, there was no documentation that EMS was contacted, which is a critical component of the emergency response protocol. The Director of Nursing (DON) confirmed that there was no documentation of EMS being called, and the Administrator was unsure of the facility's CPR policy and whether an Automated External Defibrillator (AED) was available. The failure to notify EMS during the CPR process was a significant oversight in the facility's emergency response procedures. This noncompliance with the established protocol had the potential to cause serious harm to the resident, as timely EMS intervention is crucial in such situations. The deficiency highlighted a lack of effective oversight and monitoring of facility procedures related to residents requiring CPR.
Removal Plan
- The administration failed to notify emergency management while providing Cardiopulmonary Resuscitation. The licensed nurse failed to notify 911 during CPR. It was identified the facility failed to implement all components of the Clinical Emergency Response Policy that included notifying 911 during CPR.
- The Administrator and DON were re-educated by the Regional President of Operation on Clinical Emergency Response Policy.
- The Regional Nurse Consultant re-educated the Administrator and DON on the job description.
- The Administrator will have daily calls with the Regional President of Operations regarding process of the plan, identified concerns and non-compliance identified items. The Administrator and/or DON will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR) including weekends and holidays.
- The Regional Nurse Consultant and Regional President of Operations will visit the facility daily to ensure compliance and identify any areas of concern with not notifying emergency management (911) during CPR. A review of the findings will be placed in a weekly trip report by the Regional Nurse Consultant and Regional President of Operations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 27 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wadley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Old Capitol | 9.5 mi | ★★★★★ | 9 | 0 |
| Emanuel County Nursing Home | 18.9 mi | ★★★★★ | 0 | 0 |
| Wrightsville Manor Health And Rehab | 20.9 mi | ★★★★★ | 1 | 0 |
| Twin City Trails Of Journey Llc | 24 mi | ★★★★★ | 9 | 0 |
| Smith Medical Nursing Care Ctr | 24.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Comfort Creek Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.