Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Comer Health And Rehabilitation during CMS and state inspections, most recent first.
An opened half-full lidocaine HCL injection vial was found in the medication storage room without an open date or beyond-use date. An LPN confirmed it should have been labeled, another LPN said it should be discarded, and the DON and Facility Administrator stated opened vials must be dated upon first puncture.
Incomplete infection surveillance and HAI reporting were identified when review of the IP Surveillance Binder showed HAI Summary Reports were incomplete for all months reviewed, with missing reports for several months and no analysis of trends or documented actions taken. The IP, who was also the ADON, confirmed the Surveillance Logs were incomplete and had blanks in infection monitoring and assessment sections, stating she was still orienting to the role and that IP duties were deferred because she was working medication carts due to staff shortages. The DON and Administrator confirmed blank records were unacceptable.
The facility failed to properly prepare pureed carrots for nine residents on a pureed diet. A dietary staff member used water and thickener instead of the recommended low-sodium chicken base, resulting in a lack of flavor and proper consistency. The facility's policy required food to be nutritionally adequate and palatable, but the dietary staff did not follow the recipe, which called for chicken broth. The Dietary Kitchen Manager and Registered Dietician confirmed the need for broth to enhance flavor.
The facility failed to implement care plans for two residents, leading to potential health and safety risks. One resident, with Alzheimer's and a history of brain injury, was left unsupervised outside, contrary to their care plan. Another resident, with dementia and hearing difficulties, did not receive necessary assistance with hearing aids due to staff's lack of awareness. Interviews confirmed that staff did not consistently review care plans, resulting in these deficiencies.
A resident with dementia and neuropathy was not assisted with her hearing aids, leading to communication difficulties. Despite a care plan requiring assistance, staff were unaware or did not adhere to it due to workload. Interviews confirmed the issue, highlighting a lack of adherence to the ADL plan by CNAs and LPNs.
A resident with a history of Alzheimer's and TBI, assessed as a moderate elopement risk, left the facility unsupervised after a family member opened a door for them. The facility failed to conduct regular risk assessments and lacked a policy on resident supervision, contributing to the incident.
The facility failed to prevent infection spread by improperly storing an opened bag of chips in a clean linen cart on Hall A, which also contained PPE gowns. A CNA admitted the chips were hers, and interviews with the RN/IPN, DON, and Administrator confirmed the risk of contamination and infection, especially for residents with compromised immune systems.
Unlabeled Opened Lidocaine Vial in Medication Storage Room
Penalty
Summary
The facility failed to label and date an opened multidose lidocaine HCL injection vial in the Medication Storage Room behind the nurses station between A Hall and B Hall. During observation, surveyors found one half-full vial that had been opened but was unlabeled and had no open date, leaving no way for staff to determine its beyond-use date. The facility policy titled Medication Storage in the Care Center states that medications and biologicals are to be stored safely and that outdated, contaminated, or deteriorated medications are to be promptly removed from stock. During interviews, the LPN charge nurse for A Hall confirmed that an opened lidocaine vial should be labeled with an open date or beyond-use date, and the LPN charge nurse for B Hall stated the vial should be discarded. The DON and Facility Administrator later confirmed that any medication vial opened for use must be dated upon first puncture with either the opened date or beyond-use date, and that it was unacceptable for the lidocaine vial to be left open without labeling and dating.
Incomplete Infection Surveillance and HAI Reporting
Penalty
Summary
The facility failed to provide appropriate infection control surveillance and to carry out an organized and effective infection control prevention program that included surveillance monitoring. Review of the Infection Prevention Surveillance Binder for fiscal years 2025 and 2026 showed that the HAI Summary Reports were incomplete for 12 of 12 months reviewed. The reports did not include analysis of specific trends or documented actions taken, and there was no HAI Summary Report for October 2025; the October tab contained a blank page with no monthly statistics, infection analysis rates, or actions taken. There were also no HAI reports for August 2025, January 2026, or February 2026. During interview, the Infection Preventionist, who was also the ADON, stated she had been in the IP role for the prior six months and described the facility's infection prevention program, surveillance and monitoring activities, and report processes. She stated she regularly reported to the facility QAPI meeting monthly and confirmed that the Surveillance Logs for the 2025 calendar year and January 2026 were incomplete and had blanks in the infection monitoring and assessment sections. She stated she was still orienting to her new role and that surveillance reporting and IP activities were deferred because she was working medication carts due to staff shortages. The DON and Administrator stated that the facility regularly discussed resident change of condition, infection control protocols, and observed variances in multiple venues, and both confirmed it was unacceptable for records to be left blank.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to properly prepare pureed foods, specifically pureed carrots, for nine residents who were on a pureed diet. During an observation, a dietary staff member was seen preparing pureed carrots by adding water and thickener instead of using the recommended low-sodium chicken base to achieve the correct consistency and flavor. The dietary staff member admitted to not using vegetable broth and was unsure if it was available. The facility's policy on menus emphasized that food should be nutritionally adequate, attractively served, and palatable. However, the dietary staff did not adhere to the recipe, which called for chicken broth to ensure a smooth consistency. The Dietary Kitchen Manager and the Registered Dietician confirmed that broth should have been used to enhance the flavor of the pureed carrots.
Failure to Implement Care Plans for Supervision and Hearing Aid Assistance
Penalty
Summary
The facility failed to implement care plans for two residents, R42 and R2, which had the potential to affect their health and safety. R42, who was admitted with Alzheimer's/Dementia and a history of traumatic brain injury, had a care plan that included supervision while outside due to a risk of elopement. However, on one occasion, a staff member accidentally allowed R42 to go outside unsupervised, which was confirmed by multiple staff interviews. The Director of Nursing and the Administrator acknowledged that the care plan was not followed, and staff were expected to ensure residents were not left unsupervised. For R2, who was admitted with diagnoses including dementia and chronic heart failure, the facility failed to assist with hearing aid placement as outlined in her care plan. R2 had moderate difficulty hearing and required assistance with her hearing aids due to numbness in her hands. During an interview, R2 expressed that she was unable to remove her hearing aids without assistance, and some staff were not aware of her needs. Interviews with a CNA and an LPN revealed that the ADL plan of care was not consistently reviewed, leading to a lack of awareness about R2's need for assistance with her hearing aids. The Director of Nursing confirmed that staff were expected to review the ADL plan of care to understand the services a resident needed. The failure to provide the necessary assistance with hearing aids for R2 and the lack of supervision for R42 were identified as deficiencies in the facility's implementation of care plans, potentially impacting the residents' well-being.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to assist a resident with the proper use of hearing aids, specifically in placing them in and removing them, which could result in communication barriers. The resident, who was admitted with diagnoses including dementia, heart failure, and neuropathy, expressed difficulty in removing the hearing aids due to numbness in her hands. Despite having a care plan that required assistance with hearing aids, the resident was observed without them on multiple occasions, making communication difficult. Interviews with the resident and her family representative confirmed that the lack of assistance with hearing aids was a recurring issue. Staff interviews revealed a lack of awareness and adherence to the resident's Activities of Daily Living (ADL) Plan of Care, which included assistance with hearing aids. A Certified Nursing Assistant (CNA) admitted to not regularly checking the ADL plan due to workload, while a Licensed Practical Nurse (LPN) confirmed that both CNAs and nurses were responsible for assisting with hearing aids. The Director of Nursing and the Administrator emphasized the importance of reviewing the ADL plan to ensure residents' needs are met, acknowledging that failure to do so could lead to neglecting the resident's needs.
Failure to Monitor Resident for Elopement Risk
Penalty
Summary
The facility failed to adequately monitor a resident, identified as R42, for elopement potential, which led to an incident where the resident left the facility unsupervised. R42, who has a history of Alzheimer's/dementia, Traumatic Brain Injury, and a previous pedestrian accident, was assessed as having a moderate risk for elopement. However, the facility did not complete the required quarterly Elopement Risk Assessments, with the last assessment being conducted only after the resident's elopement. On the day of the incident, R42 was able to leave the facility through a door opened by a family member, and was later found outside by the Maintenance Director. Interviews with staff revealed that there was a lack of consistent monitoring and supervision of residents at risk for elopement. The Director of Nursing stated that CNAs are expected to make regular rounds to ensure resident safety, but there was no specific policy on supervision related to residents. The Administrator confirmed that staff are instructed not to allow residents to leave the facility without checking with nursing staff, yet there was no formal policy in place to guide staff actions. This lack of policy and failure to conduct regular risk assessments contributed to the incident involving R42.
Improper Storage of Food in Clean Linen Cart
Penalty
Summary
The facility failed to prevent the spread of infections by not properly securing and storing clean linen in Hall A. During an observation, an opened bag of chips was found inside the clean linen cart, which was also used for storing personal protective equipment (PPE) gowns. A Certified Nursing Assistant (CNA) admitted that the chips were hers and acknowledged that storing food in the clean linen cart could lead to cross-contamination and compromise the cleanliness of the linens and PPE. Interviews with the Registered Nurse/Infection Prevention Nurse (RN/IPN), the Director of Nursing (DON), and the Administrator confirmed the inappropriate storage of food in the clean linen cart. They expressed concerns about the potential for contamination and infection risks, particularly for residents with open wounds or compromised immune systems. The facility's policy on infection prevention emphasizes the use of standard precautions to prevent the transmission of infectious diseases, but this incident highlighted a lapse in adherence to these protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 48 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Comer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Spring Valley | 10.7 mi | ★★★★★ | 1 | 0 |
| Brown Health And Rehabilitation | 11 mi | ★★★★★ | 7 | 0 |
| Quiet Oaks Health Care Center | 16.8 mi | ★★★★★ | 3 | 0 |
| Hartwell Health And Rehabilitation | 17.1 mi | ★★★★★ | 7 | 0 |
| Hart Care Center | 17.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Comer Health And Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.