Cycle 1
Health 2025-04-17 · Fire 2025-04-17
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Wadley, GA
Comfort Creek Nursing And Rehabilitation Center
1-star overall rating with 2-star inspections with $15,880 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
10200 U.s. Hwy 1 South, Wadley, GA
(478) 252-5254
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Beacon Health Management
Operator or chain grouping
Approved since
2002-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 1 overall / 2 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.22
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
2.79
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.81
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.64
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
3.02
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,246
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9985
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
9.06
Baseline 32.76% · Performance 26.67% · Measure score 9.06 · Achievement 9.06 · Improvement 7.20
Adjusted total nurse staffing
0
Baseline 2.93 hours · Performance 3.02 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.56% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 7.32% · Lower 95% interval 6.61% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 94.59% |
95.27%
0.7 pts worse
|
Numerator 35 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 28.57% |
53.69%
25.1 pts worse
|
Numerator 6 · Denominator 21 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 9 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 2.24% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 102 |
| Staff flu vaccination coverage | 10.49% |
42%
31.5 pts worse
|
Numerator 15 · Denominator 143 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 11 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.2%
8.1 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 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 | 1.4% |
3.2%
1.8 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 1.3% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
9.6%
6.5 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.4% · Q3 4.2% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.9%
About the same
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 9.5% · Q3 6.0% · Q4 3.2% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
20.7%
0.7 pts better
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 17.2% · Q3 20.0% · Q4 21.0% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 41.2% |
21.4%
19.8 pts worse
|
16.7%
24.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.9% · Q2 42.9% · Q3 38.2% · Q4 46.2% · 4Q avg 41.2% · 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 | 12.1% |
17.9%
5.8 pts better
|
16.3%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 10.6% · Q3 17.2% · Q4 6.6% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.3% |
16.2%
8.1 pts worse
|
14.9%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 25.8% · Q3 23.2% · Q4 20.7% · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
1.1%
2.3 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.9% · Q3 3.6% · Q4 2.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.5%
1.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.4% |
16.1%
4.3 pts worse
|
19.8%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 20.1% · Q3 15.2% · Q4 26.0% · 4Q avg 20.4% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
6.2%
0.6 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.0% · Q3 6.9% · Q4 7.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
80.4%
18.9 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
12.2%
6.6 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 6.9% · Expected 13.8% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
78.2%
19.7 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.4% |
24.2%
5.8 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 20.7% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-08 · Fire 2023-10-08
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-02-02 · Fire 2023-02-02
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-05-30
D · Potential for more than minimal harm
2023-10-08
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 2023-11-20
D · Potential for more than minimal harm
2023-10-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-02-02
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-17
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
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 2025-05-30
D · Potential for more than minimal harm
2025-04-17
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 2025-05-30
D · Potential for more than minimal harm
2025-04-17
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
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 2025-05-30
D · Potential for more than minimal harm
2025-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-30
J · Immediate jeopardy
2024-06-07
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-07-03
J · Immediate jeopardy
2024-06-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-03
D · Potential for more than minimal harm
2023-11-30
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 2024-01-01
D · Potential for more than minimal harm
2023-11-30
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-10-08
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-02-02
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
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 2023-03-19
E · Potential for more than minimal harm
2023-02-02
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-03-19
E · Potential for more than minimal harm
2023-02-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-02-02
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2023-03-19
E · Potential for more than minimal harm
2023-02-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-02
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 2023-03-19
D · Potential for more than minimal harm
2023-02-02
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 2023-03-19
D · Potential for more than minimal harm
2023-02-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-02
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-02
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 2023-03-19
D · Potential for more than minimal harm
2023-02-02
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 2023-03-19
D · Potential for more than minimal harm
2023-02-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-02
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 2023-03-19
D · Potential for more than minimal harm
2023-02-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-03-19
C · Minimal harm
2023-02-02
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-03-19
Penalties and ownership
What sits behind the stars
$15,880
2024-06-07
Fine
Fine · fine $15,880
Fine
Ownership
Hsp Southern Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Wertheim, Bruce
5% Or Greater Indirect Ownership Interest · Individual
Beacon Health Management LLC
Operational/Managerial Control · Organization
Mcdowell, Lynette
W-2 Managing Employee · Individual
Wertheim, Bruce
Operational/Managerial Control · Individual
Wertheim, Bruce
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Pruitthealth - Old Capitol
Louisville, GA
2-star overall rating with 1-star inspections with $28,179 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Emanuel County Nursing Home
Swainsboro, GA
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Wrightsville Manor Health And Rehab
Wrightsville, GA
1-star overall rating with 1-star inspections with $74,208 in total fines with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Jump out