Comfort Cove

The facility failed to follow protocols regarding resident assessments when a significant change in baseline condition is identified. The regulation requires monitoring and assessment within specific timeframes following changes in activities of daily living, weight, or behavior.

The facility failed to ensure that 2 of 3 sampled residents were tested for Tuberculosis (TB) disease in compliance with public health guidelines. Specifically, there was no record of a completed TB test for Resident #3, despite their admission on 04/18/25.

The facility failed to ensure necessary referral and follow-up care for a resident's acute health needs. Specifically, the facility did not facilitate required appointments with a pain clinic, dentist, and eye doctor, leaving the resident's chronic pain unaddressed.

The facility failed to comply with the Suspension of Admissions (SOA) notification by admitting a resident on 03/29/24, which occurred after the notification date of March 5, 2024. Interviews with staff and the administrator revealed that the facility was unaware it was under a suspension of admissions at the time of the resident's arrival.

The facility failed to ensure that the required 80-hour personal care training and competency evaluation was completed within six months of hire for 2 out of 4 sampled staff members (Staff A and D).

The facility failed to ensure that required 80-hour personal care training was completed within six months of hire for 2 of 4 sampled staff members. Specifically, documentation for Staff A showed no evidence of completed personal care training despite the employee performing personal care tasks such as bathing and transferring residents.

The facility failed to ensure that 2 of 3 sampled staff members who provide personal care had successfully completed the required 80-hour personal care training and competency evaluation program within six months of hire. Specifically, there was no documentation of training for Staff A, and the facility could not locate the required training records for Staff B.

Two of four corridors leading to fire exit doors were obstructed with old furnishings, mattresses, a shower chair, and a wheelchair. This included items placed against the back hallway exit door and items on the fire escape landing, which prevented the exit door from opening fully.

The facility failed to ensure that food stored in the refrigerator was protected from contamination.

The facility failed to keep corridors free of equipment and obstructions. Specifically, two of four corridors leading to fire exit doors were blocked by items including old mattresses, chests of drawers, a shower chair, a wheelchair, and a rocking chair. Interviews with residents indicated that the back exit door is frequently used as a storage area for broken furniture and discarded items.