Cycle 1
Health 2025-01-16 · Fire 2025-01-16
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Comer, GA
Comer Health And Rehabilitation
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2430 Paoli Road, Comer, GA
(706) 783-5116
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
2009-01-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
48 facilities
Chain averages 4 overall / 4 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.96
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,061
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9944
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.96
Performance 18.67% · Measure score 5.96 · Achievement 5.96 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.33
Performance 6.84% · Measure score 3.33 · Achievement 3.33 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.71
Baseline 38.46% · Performance 44.44% · Measure score 4.71 · Achievement 4.71 · Improvement 0
Adjusted total nurse staffing
2.59
Baseline 3.23 hours · Performance 3.81 hours · Measure score 2.59 · Achievement 2.59 · Improvement 1.8
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 7.14% · Lower 95% interval 6.56% |
| Discharge to community | 56.49% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 55.26% · Lower 95% interval 44.4% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 49 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 18 · Denominator 42 |
| Discharge mobility score | 23.81% |
50.94%
27.1 pts worse
|
Numerator 10 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 4.08% |
2.29%
1.8 pts worse
|
Numerator 2 · Denominator 49 · Adjusted rate 2.92% |
| Healthcare-associated infections requiring hospitalization | 6.84% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 112 |
| Staff flu vaccination coverage | 79.63% |
42%
37.6 pts better
|
Numerator 86 · Denominator 108 |
| Discharge function score | 28.57% |
56.45%
27.9 pts worse
|
Numerator 12 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 36.36% |
25.2%
11.2 pts better
|
Numerator 12 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.2
0.4 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.0
1.3 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
91.2%
1.4 pts worse
|
93.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.7% · Q2 88.9% · Q3 91.7% · Q4 89.7% · 4Q avg 89.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.0%
2.4 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.4% |
3.2%
4.2 pts worse
|
3.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.2% · Q3 9.7% · Q4 10.3% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
5.9%
1 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.6% · Q3 5.0% · Q4 14.3% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.0% |
20.7%
0.3 pts worse
|
19.6%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.5% · Q3 21.3% · Q4 24.6% · 4Q avg 21.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
21.4%
8.2 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 14.0% · Q3 13.0% · Q4 17.4% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.2% |
17.9%
3.3 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 29.4% · Q3 14.0% · Q4 17.6% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
16.2%
0.8 pts worse
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 22.0% · Q3 14.0% · Q4 13.5% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.1%
0.4 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 2.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
2.5%
1.8 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 1.4% · Q3 4.2% · Q4 4.5% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.0% |
16.1%
3.1 pts better
|
19.8%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 11.8% · Q3 15.8% · Q4 13.7% · 4Q avg 13.0% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
6.2%
1.7 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 10.5% · Q3 8.9% · Q4 5.4% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.2% |
80.4%
19.2 pts worse
|
81.7%
20.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.1% · Q2 79.1% · Q3 51.9% · Q4 42.5% · 4Q avg 61.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.4% |
12.2%
7.8 pts better
|
12.0%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 4.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.1% |
78.2%
5.9 pts better
|
79.7%
4.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
24.2%
6.9 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 17.0% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-29 · Fire 2022-09-29
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-08-08 · Fire 2019-08-08
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-02
F · Potential for more than minimal harm
2025-01-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-02
E · Potential for more than minimal harm
2025-01-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-02
D · Potential for more than minimal harm
2025-01-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-02
D · Potential for more than minimal harm
2025-01-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-02
D · Potential for more than minimal harm
2025-01-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-02
D · Potential for more than minimal harm
2025-01-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-02
D · Potential for more than minimal harm
2025-01-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-02
D · Potential for more than minimal harm
2025-01-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-02
D · Potential for more than minimal harm
2025-01-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-02
D · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-02
E · Potential for more than minimal harm
2022-09-29
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-09-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-09-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-09-29
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-11-13
D · Potential for more than minimal harm
2019-08-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-09-22
D · Potential for more than minimal harm
2019-08-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-09-22
D · Potential for more than minimal harm
2019-08-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-09-22
D · Potential for more than minimal harm
2019-08-08
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2019-09-22
Penalties and ownership
What sits behind the stars
Ownership
Arnold-Baughns, Ashley
Operational/Managerial Control · Individual
Cable, Paul
Corporate Director · Individual
Clinical Services Inc
Operational/Managerial Control · Organization
Community Health Systems Inc
5% Or Greater Direct Ownership Interest · Organization
Dennis, Kathryn
Corporate Director · Individual
Health Scholarships Inc
5% Or Greater Direct Ownership Interest · Organization
Lambert, Reno
Operational/Managerial Control · Individual
Madison County Holdings, LLC
5% Or Greater Mortgage Interest · Organization
Moody, Teresa
Corporate Officer · Individual
Nichols, Joseph
Corporate Director · Individual
Rollins, Ronnie
Corporate Director · Individual
Ryals, Keisha
Operational/Managerial Control · Individual
Wall, Joseph
Corporate Director · Individual
Warnock, Ralph
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Pruitthealth - Spring Valley
Elberton, GA
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#2
Brown Health and Rehabilitation
Royston, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Quiet Oaks Health Care Center
Crawford, GA
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Jump out