Facility profile · CCN 115679
Comfort Creek Nursing And Rehabilitation Center
32 federal citations on record , including 2 at the Immediate Jeopardy level, and 1 federal enforcement actions totaling $15,880.
Record summary
Federal record · Q1 202632
Total citations
15
Last 3 years
2
Actual harm+
1
Federal penalties
$15,880
Total fines
1
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
32 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Apr 17, 2025 | F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Complaint |
| Apr 17, 2025 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Complaint |
| Apr 17, 2025 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint |
| Apr 17, 2025 | F625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D | Complaint |
| Apr 17, 2025 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint |
| Apr 17, 2025 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Apr 17, 2025 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | E | Standard |
| Apr 17, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Jun 7, 2024 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | J | Complaint |
| Jun 7, 2024 | F678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | J | Complaint |
| Nov 30, 2023 | F693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D | Complaint |
| Nov 30, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Oct 8, 2023 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Oct 8, 2023 | F644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Standard |
| Oct 8, 2023 | F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D | Standard |
| Feb 2, 2023 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D | Standard |
| Feb 2, 2023 | F888 | Ensure staff are vaccinated for COVID-19 | C | Standard |
| Feb 2, 2023 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E | Standard |
| Feb 2, 2023 | F841 | Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | E | Standard |
| Feb 2, 2023 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Feb 2, 2023 | F802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | F | Standard |
| Feb 2, 2023 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Standard |
| Feb 2, 2023 | F727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | F | Standard |
| Feb 2, 2023 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D | Standard |
| Feb 2, 2023 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | E | Standard |
| Feb 2, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Feb 2, 2023 | F688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | E | Standard |
| Feb 2, 2023 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Feb 2, 2023 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Feb 2, 2023 | F610 | Respond appropriately to all alleged violations. | D | Standard |
| Feb 2, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard |
| Feb 2, 2023 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Standard |
Federal enforcement history
Federal regulators have imposed 1 enforcement actions against this facility, including 1 civil money penalties totaling $15,880 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Jun 7, 2024 | Fine | $15,880 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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