Comfort Creek Nursing And Rehabilitation Center

F-F678.

The facility implemented the following actions to remove the IJ:

1. The administration failed to notify emergency management while providing Cardiopulmonary Resuscitation

on [DATE REDACTED]. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 115679 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115679 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Comfort Creek Nursing and Rehabilitation Center 10200 U.S. Hwy 1 South Wadley, GA 30477

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 2. The Administrator and DON were re-educated on [DATE REDACTED] by the Regional [NAME] President of Operation

on Clinical Emergency Response Policy. Level of Harm - Immediate jeopardy to resident health or 3. On [DATE REDACTED], the Regional Nurse Consultant re-educated the Administrator and DON on the job description. safety 4. The Administrator will have daily calls with the Regional [NAME] President of Operations regarding Residents Affected - Few process of the plan, identified concerns and non-compliance identified items beginning on [DATE REDACTED]. 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.

5. The Regional Nurse Consultant and Regional [NAME] President of Operations will visit the facility daily beginning [DATE REDACTED] to ensure compliance and identify any areas of concern with not notifying emergency management (9I I) during CPR, beginning on [DATE REDACTED]. A review of the findings will be placed in a weekly trip report by the Regional Nurse Consultant and Regional [NAME] President of Operations.

6. All corrective action was completed on [DATE REDACTED].

7. The immediacy of the IJ was removed on [DATE REDACTED].

The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:

1. The Administration failed to notify emergency management while providing Cardiopulmonary Resuscitation on [DATE REDACTED]. 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.

2. A review of the sign-in sheet dated [DATE REDACTED] revealed an in-service conducted by the Regional [NAME] President of Operation provided to the Administrator and DON. Education included handouts on Clinical Emergency Response Management, Cardiopulmonary Resuscitation (CPR) standards and procedures, and Emergency Crash Cart standards and procedures. Confirmed education with DON on [DATE REDACTED] at 8:45 am, and Administrator on [DATE REDACTED] at 11:30 am.

3. A review of the sign-in sheet dated [DATE REDACTED] revealed an in-service conducted by the Regional Nurse Consultant provided to the Administrator and DON. Confirmed education with the DON on [DATE REDACTED] at 11:00 am.

4. Beginning on [DATE REDACTED], the Administrator will have daily calls with the Regional [NAME] President of Operations regarding the plan's process, identified concerns, and non-compliance 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.

Interview on [DATE REDACTED] at 8:30 am with the DON revealed there was a change in leadership. The DON stated that the Administrator who was there is no longer there, and she has stepped into the role of the Administrator, and her Administrator license was verified.

5. Regional Nurse Consultant and Regional [NAME] President of Operations were observed at the

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 115679 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115679 B. Wing 06/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Comfort Creek Nursing and Rehabilitation Center 10200 U.S. Hwy 1 South Wadley, GA 30477

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 facility on [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED]. Confirmed with LPN DD on [DATE REDACTED] at 11:55 am revealed she saw

the Regional Nurse Consultant and the Regional [NAME] President of Operations at the facility. Level of Harm - Immediate jeopardy to resident health or 6. All corrective action was completed on [DATE REDACTED]. safety 7. The immediacy of the IJ was removed on [DATE REDACTED]. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 115679