Cycle 1
Health 2025-11-18 · Fire 2024-05-16
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Laurel, MS
Comfort Care Nursing Center
2-star overall rating with 2-star inspections with 12 recent health deficiencies
1100 West Drive, Laurel, MS
(601) 422-0022
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
109
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2022-09-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.57
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
3.15
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
5.04
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
6.00
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
6,729
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.61% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.14
Performance 6.60% · Measure score 4.14 · Achievement 4.14 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.07
Performance 47.06% · Measure score 4.07 · Achievement 4.07 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.55
Performance 4.37 hours · Measure score 4.55 · Achievement 4.55 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.43% |
10.72%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 140 · Observed rate 13.57% · Lower 95% interval 9.88% |
| Discharge to community | 51.45% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 52.42% · Lower 95% interval 43.68% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.4% |
95.27%
3.1 pts better
|
Numerator 123 · Denominator 125 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 125 |
| Discharge self-care score | 54.26% |
53.69%
0.6 pts better
|
Numerator 51 · Denominator 94 |
| Discharge mobility score | 27.66% |
50.94%
23.3 pts worse
|
Numerator 26 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 125 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.6% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 4.96% · Lower 95% interval 3.99% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 150 |
| Staff flu vaccination coverage | 81.82% |
42%
39.8 pts better
|
Numerator 108 · Denominator 132 |
| Discharge function score | 46.81% |
56.45%
9.6 pts worse
|
Numerator 44 · Denominator 94 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 88 · Denominator 88 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 17 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.4
0.1 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.9
0.8 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
95.7%
4.1 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.0%
3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.2%
0.1 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.7% · Q3 3.8% · Q4 4.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
1.6%
1.3 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 12.3% |
6.1%
6.2 pts worse
|
5.4%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 13.6% · Q3 15.3% · Q4 12.9% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
24.4%
1.3 pts better
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 24.3% · Q3 25.2% · Q4 20.8% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
23.4%
14 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 9.8% · Q3 10.1% · Q4 9.3% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 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 | 37.5% |
22.8%
14.7 pts worse
|
16.3%
21.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 43.4% · Q3 25.9% · Q4 35.2% · 4Q avg 37.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.1% |
20.6%
10.5 pts worse
|
14.9%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 25.3% · Q3 31.8% · Q4 33.7% · 4Q avg 31.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.5%
1.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.5%
1 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.0% · Q3 1.0% · Q4 2.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
21.4%
0.9 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 15.4% · Q3 21.1% · Q4 23.7% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
6.9%
0.1 pts better
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.8% · Q3 6.2% · Q4 6.1% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
87.9%
7.8 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.8% · Q2 94.7% · Q3 98.7% · Q4 98.9% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
15.3%
6.2 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.0% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
2.6%
1.7 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
84.6%
10.2 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
27.9%
0.2 pts better
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 21.7% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2022-09-29
1 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-29 · Fire
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-11-18
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-11-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-18
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 2025-12-18
D · Potential for more than minimal harm
2025-11-18
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-06-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-06-12
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 2025-07-24
E · Potential for more than minimal harm
2025-06-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-06-12
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-06-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-24
D · Potential for more than minimal harm
2024-05-16
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-06-21
Penalties and ownership
What sits behind the stars
Ownership
East, Stephen
Corporate Officer · Individual
Gibbes, Gregg
Operational/Managerial Control · Individual
Gibbes, Gregg
Corporate Officer · Individual
Hasbargen, Brittany
Operational/Managerial Control · Individual
Hicks, Judith
Operational/Managerial Control · Individual
Pippen, Alexander
Operational/Managerial Control · Individual
South Central Regional Medical Center
Operational/Managerial Control · Organization
Staines, Lane
Corporate Director · Individual
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