Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Comfort Care Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and severely impaired cognition exited behind a visitor and remained outside unattended for about two minutes before a social worker redirected him back inside. Front desk staff were distracted by computer issues and did not observe the exit, and the resident had been assessed as not at risk for wandering or elopement.
Surveyors identified multiple deficiencies in food storage and handling, including undated and unlabeled prepared foods, exposed and spoiled produce, and improper handling of ready-to-eat foods by staff using gloved hands. Dry goods were left uncovered, and items requiring refrigeration were improperly stored. Staff and administration acknowledged these lapses in food safety and sanitation protocols.
The facility did not promptly review or resolve repeated resident grievances about inadequate housekeeping, particularly on weekends when no dedicated staff were assigned. Multiple residents reported ongoing issues with unclean rooms and unemptied trash, and these concerns were documented over several months without effective response from management, despite their awareness of the problem.
Staff did not report allegations of verbal abuse by an LPN towards two residents, despite multiple accounts describing the nurse's behavior as loud and demeaning. Additionally, multiple reports of stolen resident funds were not reported to the State Agency, with the Administrator stating a lack of awareness of the reporting requirement. These actions were not in accordance with facility policy, which mandates immediate reporting of such incidents.
Two residents, both cognitively intact and with significant medical histories, reported being treated in a demeaning, intimidating, and disrespectful manner by an LPN, including raised voices, sarcastic remarks, and rough tones during medication administration. Staff interviews confirmed the LPN also used vulgar language and insults toward coworkers, contributing to an environment lacking in dignity and respect for both residents and staff.
Two cognitively intact residents reported that an LPN spoke to them in a loud, demeaning, and intimidating manner, with one resident feeling degraded and afraid after a medication-related interaction. Another resident described the LPN as using a rough tone and intimidating residents. Staff interviews confirmed the LPN's negative, vulgar, and insulting behavior towards both residents and staff, including the use of profane language. The facility's policy prohibits abuse, but these incidents demonstrate a failure to prevent verbal abuse.
Multiple residents reported theft of personal funds, with amounts ranging from $15 to over $100, from their rooms or belongings. Despite notifying the Resident Council President and various staff, including the Administrator, DON, and Social Service Director, residents did not receive updates or reimbursement. The Social Service Director confirmed forwarding statements to the Administrator but was unaware of any investigation outcomes. The Administrator acknowledged the reports but did not reimburse residents, citing uncertainty about the exact amounts. Residents affected had varying cognitive abilities and medical conditions, and the facility did not follow its policy to protect resident property.
A wound care cart containing medications such as Nystatin, Santyl, and Dakin's solution was left unlocked and unattended for fifteen minutes, with wound cleanser unsecured on top. An RN later returned to secure the cart. Both the RN and DON confirmed that the cart should have been locked at all times when not in use, in accordance with facility policy.
A third-party LCSW provided psychosocial therapy to multiple residents without informing facility staff, the physician, or resident representatives, as required by facility policy. The LCSW accepted self-referrals from cognitively intact residents and did not disclose service recipients, resulting in a lack of physician orders and no notification to responsible parties for the initiation of therapy.
The facility did not develop or implement care plans that included psychosocial therapy services provided by an LCSW for residents receiving such therapy. Staff confirmed that no documentation or care plan interventions reflected these services, as the LCSW, a third-party provider, refused to share resident information due to confidentiality. This resulted in a lack of coordination and individualized interventions for residents receiving therapy for depression or major depressive disorder.
The facility did not obtain physician orders for psychosocial therapy services provided by a third-party LCSW, resulting in therapy being delivered without appropriate physician oversight or documentation. Multiple residents received cognitive behavioral therapy for depression or related conditions, but there were no physician orders, referrals, or care plans in place, and the LCSW did not share session information with facility staff.
A Licensed Clinical Social Worker provided cognitive behavioral therapy to multiple residents without physician oversight, formal referral, or interdisciplinary coordination. The LCSW accepted self-referrals from cognitively intact residents and did not communicate with facility staff or medical personnel, resulting in a lack of psychosocial assessments, care planning, and monitoring for those receiving therapy.
A Licensed Clinical Social Worker provided individual psychosocial therapy to multiple residents but kept all therapy documentation separate from the facility's medical record system, resulting in incomplete and inaccessible records. Facility staff were unaware of which residents were receiving therapy or the details of the services, as the LCSW did not share any documentation, leaving the interdisciplinary team without access to pertinent clinical information.
The facility failed to submit accurate PBJ staffing data to CMS for December 2023, resulting in a report of no RN hours and less than 24 hours/day licensed nursing coverage for multiple days. The error was due to an interface issue, and staff were unaware of the inaccuracy.
Failure to Supervise Allowed Resident to Exit Unattended
Penalty
Summary
The facility failed to provide adequate supervision to prevent an unsupervised exit when a resident with dementia and severely impaired cognition left the facility behind a visitor and remained outside unattended for approximately two minutes before being redirected back inside. The resident was admitted with a diagnosis of dementia without behavioral disturbance, had a BIMS score of 3, and had been assessed as not at risk for wandering or elopement. According to the facility investigation and staff interviews, front desk personnel were pushing the door buzzer for visitors while distracted by computer issues, and neither staff member observed the resident exiting. Surveillance video showed the resident outside on the facility sidewalks, and the administrator reported the resident ambulated about 80 feet from the facility before the social worker saw him on the sidewalk and redirected him back into the building. The social worker confirmed the resident appeared confused and should not have been outside alone.
Deficient Food Storage, Labeling, and Handling Practices Observed in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and handling practices during two kitchen inspections. In Refrigerator #1, several trays of prepared salads, bowls of pudding, fruit, and staff food were found without date labels, and some items were in direct contact with each other. Additional items, such as blueberry cobbler, fruit cocktail, and prefilled whipped topping, were also missing required labeling or were past their use-by dates. In Refrigerator #3, raw chicken tenders were left exposed with the lid off, cheese slices were left open and dried out, and produce such as strawberries and oranges were found to be spoiled or overly ripe. Dry storage bins for sugar, rice, and cornmeal were left uncovered, and an opened bag of grits was not securely closed. The Food Service Supervisor acknowledged these deficiencies and stated that it was his responsibility to ensure food safety. Further observations revealed unsanitary handling of ready-to-eat foods by kitchen staff. Staff members were seen using gloved hands to pick up and move bread and noodles directly on residents' plates, contrary to food safety protocols. An opened bottle of lemon juice requiring refrigeration was found improperly stored on a shelf. Interviews with staff confirmed awareness of proper food handling procedures, but lapses were attributed to forgetfulness. The Administrator acknowledged the issues with food storage, labeling, and unsanitary handling, emphasizing that all kitchen staff are responsible for maintaining food quality and sanitation.
Failure to Timely Address Resident Grievances Regarding Housekeeping
Penalty
Summary
The facility failed to review and resolve multiple resident grievances regarding housekeeping in a timely and effective manner, as evidenced by ongoing complaints documented in three consecutive months of Resident Council meeting minutes. Residents repeatedly expressed concerns about unclean floors, unemptied trash, and a lack of general housekeeping, particularly on weekends when no dedicated housekeeping staff were assigned. These grievances were raised during council meetings but did not receive a response or resolution from facility management. Specific residents reported that their rooms were left unclean throughout the weekend, with one resident managing persistent odors and unclean conditions due to accidents until staff returned on Monday. Interviews with the Housekeeping Manager and Administrator confirmed awareness of the complaints and acknowledged that staffing shortages, especially on weekends, contributed to the unresolved issues. Despite being aware of the ongoing concerns, the facility did not take prompt or effective action to address the grievances, resulting in persistent environmental issues for the residents.
Failure to Report Allegations of Verbal Abuse and Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure timely reporting of allegations of verbal abuse and misappropriation of resident property as required by federal regulations and its own policies. Specifically, staff did not report allegations of verbal abuse involving two residents, despite both the residents and a witness describing the LPN's behavior as loud, demeaning, and intimidating. The LPN admitted to speaking loudly, and a CNA corroborated the negative and vulgar conduct. The incident was not reported to the Director of Nursing, and the DON confirmed she was unaware of the situation, stating that staff are required to report such allegations and that the nurse would have been removed from resident care pending investigation if reported. Additionally, the facility failed to report multiple allegations of theft of resident funds involving five residents to the State Agency. The Administrator acknowledged that several residents had reported missing money but stated that reimbursement was not provided due to lack of verification of the amounts lost. The Administrator also admitted to not knowing that such incidents needed to be reported to the State Agency. The facility's policy requires immediate reporting of abuse and misappropriation allegations to appropriate authorities, but this protocol was not followed in these cases.
Failure to Ensure Residents' Right to Dignity and Respect by Nursing Staff
Penalty
Summary
Licensed nursing staff failed to treat residents with dignity and respect, as evidenced by multiple reports from both residents and staff. One resident reported that a night shift LPN raised her voice, spoke in a demeaning and intimidating tone, and argued with her about taking a newly prescribed medication that was causing stomach upset. The resident described feeling talked down to, afraid, degraded, and intimidated. The resident's roommate confirmed the LPN's loud and intimidating behavior, describing the interaction as uncalled for and rude. Another resident, who is a former CNA, also reported that the same nurse spoke to residents in a rough tone, used her authority to intimidate, and treated them like children, which she deemed inappropriate for the setting. Staff interviews further corroborated these concerns. A CNA reported that the LPN had spoken to her in a demeaning and vulgar manner, including the use of profanity and insults, leading the CNA to avoid working with the nurse. The facility scheduler confirmed that the CNA, who rarely complains, reported being verbally abused by the LPN during a night shift. Both the Administrator and the DON acknowledged that all residents have the right to be treated with dignity and respect. The residents involved were cognitively intact, as indicated by their BIMS scores, and had medical histories including hemiplegia, hemiparesis following cerebral infarction, and acute on chronic systolic congestive heart failure.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse by staff, as evidenced by multiple interviews and record reviews involving two cognitively intact residents. One resident reported that a night shift LPN raised her voice, spoke in a demeaning and intimidating manner, and responded sarcastically when questioned about a new medication, making the resident feel degraded, afraid, and intimidated. The resident's roommate confirmed the LPN's loud and intimidating behavior, and another resident described the nurse as using a rough tone, talking down to residents, and using her authority to intimidate. Both residents expressed that the nurse's conduct was inappropriate and made them feel uncomfortable and fearful. Staff interviews corroborated the residents' accounts, with a CNA reporting that the same LPN was extremely negative, loud, vulgar, and insulting to both staff and residents during the shift in question. The CNA recalled the LPN using profane language towards staff and described her as intimidating. The facility scheduler confirmed that the CNA, who rarely complains, reported verbal abuse by the LPN, including cursing and name-calling. The Director of Nursing stated she had not been informed of the incident but noted a second, unrelated complaint about the same LPN's verbal abuse towards staff on the same night. The facility's policy prohibits abuse, neglect, and exploitation, but the events described indicate a failure to implement these protections.
Failure to Protect Residents from Misappropriation of Funds
Penalty
Summary
The facility failed to protect residents from misappropriation of their funds and did not implement corrective action or reimburse residents after multiple reports of missing money. Several residents reported to the Resident Council President and staff that their personal funds, ranging from $15 to over $100, were stolen from their rooms or personal belongings. Despite these reports, residents did not receive updates on the status of their complaints or any reimbursement for their losses. The facility's policy requires protection of resident property, but this was not followed in these cases. Interviews with residents revealed that they had reported the thefts to various staff members, including the Administrator, DON, Social Service Director, and security personnel. However, the residents consistently stated that no follow-up or resolution was provided. The Social Service Director confirmed that she collected statements and forwarded them to the Administrator, but was unaware of any investigation outcomes or reimbursements. The Administrator acknowledged the reports of stolen money but stated that, in his view, the facility was not obliged to reimburse residents unless the exact amounts could be confirmed. The affected residents had varying degrees of cognitive function, with some being cognitively intact and others having moderate impairment. Their medical histories included conditions such as heart disease, heart failure, anxiety disorder, anemia, and hemiplegia. The lack of action and communication from the facility left residents feeling unsafe, discouraged, and financially vulnerable, as their reports of missing funds were not addressed or resolved.
Unattended and Unlocked Wound Care Cart with Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored to prevent unauthorized access. On one of the survey days, a wound care cart located in the 200 Hall was observed to be unlocked and unattended for fifteen minutes, with wound cleanser left unsecured on top of the cart. The cart contained medications such as Nystatin, Santyl, Dakin's solution, and other wound care agents. The cart was only locked after a registered nurse returned, placed the unsecured cleanser inside, and secured the cart. Interviews with the registered nurse and the Director of Nursing confirmed that the cart should have been locked at all times when not in use, as per facility policy. The nurse explained that the keypad locking mechanism was malfunctioning, requiring manual locking, and admitted to forgetting to lock the cart after use. The Director of Nursing and the Administrator both acknowledged the expectation that all treatment carts remain locked and that no medications or supplies should be left unsecured.
Failure to Notify Physician and Resident Representative of Initiation of Psychosocial Therapy
Penalty
Summary
The facility failed to notify the physician and the resident representative (RR) when individual psychosocial therapy services were initiated for three sampled residents, with the potential to affect all 21 residents receiving such therapy. According to the facility's policy, notification of the resident, consultation with the physician, and notification of the RR are required when there are changes in treatment or services. However, a Licensed Certified Social Worker (LCSW) from a third-party provider delivered psychosocial therapy to residents without informing facility staff, the physician, or the RRs. The LCSW stated that all referrals were self-initiated by cognitively intact residents and did not share information about which residents were receiving services, citing confidentiality. Interviews with facility staff, including the Social Services staff member, Registered Nurse, Nurse Practitioner, and the physician, confirmed that they were unaware of which residents were receiving therapy from the LCSW. As a result, no physician orders were obtained, and no notifications were made to the RRs regarding the initiation of therapy. The Administrator acknowledged that the facility did not follow its own policy for physician and RR notification for residents receiving psychosocial services from the LCSW. Record reviews for the three sampled residents showed that each had a BIMS score indicating they were cognitively intact and had no documented behaviors or mood symptoms at the time of assessment. Documentation from the LCSW confirmed that these residents received Cognitive Behavioral Therapy for depression on multiple occasions, but there was no evidence in the medical records that the physician or RRs were notified about the initiation or continuation of these services.
Failure to Include LCSW Psychosocial Therapy in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the psychosocial needs of residents receiving individual therapy from a Licensed Clinical Social Worker (LCSW). Specifically, the care plans for three sampled residents did not include the ongoing psychosocial therapy services provided by the LCSW, nor did they reflect coordination of care, consistent monitoring, or individualized interventions based on the residents' psychosocial needs. This omission was identified through record reviews, interviews with facility staff, and review of facility policy, which requires that all identified needs, including mental and psychosocial, be addressed in the care plan with measurable objectives and timeframes. Interviews with facility staff, including the Social Services Director, RN, LPN/MDS Coordinator, and ADON, confirmed that there were no behavioral care plan interventions or documentation related to the LCSW's services. The LCSW, who is a third-party provider and not employed by the facility, refused to share information about the residents she served, citing confidentiality. As a result, the facility was not informed of the therapy sessions, and no physician's orders or documentation were provided to support the inclusion of these services in the residents' care plans. The interdisciplinary team was not involved in developing or reviewing care plans related to these psychosocial therapy services. Record reviews for the three residents showed that each had received cognitive behavioral therapy from the LCSW for depression or major depressive disorder, with therapy provided on a regular basis. Despite this, their medical records and care plans did not reflect these services or any related interventions. The lack of documentation and care planning for these services affected not only the three sampled residents but also had the potential to impact all 21 residents who received psychosocial therapy from the LCSW.
Failure to Obtain Physician Orders for Third-Party Psychosocial Therapy Services
Penalty
Summary
The facility failed to ensure that psychosocial therapy services provided by a third-party Licensed Clinical Social Worker (LCSW) were delivered and documented according to professional standards. Specifically, the LCSW provided ongoing behavioral therapy to residents without obtaining physician's orders, and the facility did not have records of referrals, care plans, or notifications to resident representatives for these services. Interviews with facility staff, including the Social Services Director, RN, Assistant Director of Nursing, and the physician, confirmed that no physician's orders or referrals were in place for the residents receiving these services. The LCSW also did not share resident names or session documentation with the facility, citing confidentiality, and the facility's policy required physician's orders for all services provided to residents. Record reviews for three sampled residents revealed that each had received multiple sessions of cognitive behavioral therapy from the LCSW for conditions such as major depressive disorder and depression, despite having no documented behaviors or mood symptoms on their Minimum Data Set (MDS) assessments. The medical records for these residents did not contain any physician's orders reflecting the behavioral therapy they received. The deficiency was identified as having the potential to affect all 21 residents who received psychosocial therapy from the LCSW.
Failure to Coordinate and Oversee Behavioral Health Services Provided by External LCSW
Penalty
Summary
The facility failed to identify, assess, and coordinate behavioral health services for three residents who were receiving individual psychosocial therapy from a Licensed Clinical Social Worker (LCSW). The LCSW, employed by a local hospital's behavioral health program, provided ongoing cognitive behavioral therapy to residents within the facility without physician oversight, formal referral, or interdisciplinary coordination. The LCSW accepted self-referred residents, regardless of whether a clinical need had been identified, and did not communicate with facility staff, the nurse practitioner, or the physician regarding which residents were receiving services. Interviews with facility staff, including the Social Services Director, RN, ADON, Administrator, NP, and Physician, confirmed that there was no communication or coordination regarding the therapy services being provided. The facility was unable to conduct appropriate psychosocial assessments, implement monitoring interventions, or evaluate the effectiveness or necessity of the therapy. The LCSW stated that, due to confidentiality, she did not inform facility staff or medical personnel of the residents receiving therapy, and all referrals were self-initiated by cognitively intact residents. Record reviews showed that the LCSW provided therapy to 21 residents, including the three sampled residents, none of whom exhibited behaviors or mood symptoms according to their MDS assessments. There were no physician orders, care plans, or notifications to resident representatives regarding the therapy services. The lack of oversight and coordination resulted in the facility being unaware of the therapy being provided, with no monitoring or follow-up for changes in residents' psychosocial or behavioral health status.
Failure to Integrate Psychosocial Therapy Documentation into Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for all residents receiving individual psychosocial therapy. Specifically, a Licensed Clinical Social Worker (LCSW) provided therapy to approximately 21 residents but kept all therapy documentation in a locked cabinet, separate from the facility's medical record system. The LCSW did not share progress notes or any documentation with the facility, citing confidentiality, which resulted in incomplete medical records for residents receiving these services. Facility staff, including the Social Services Director, RN, and Assistant Director of Nursing, confirmed that they did not have access to information about which residents were receiving therapy or the details of the services provided. Record reviews for three sampled residents revealed that while the LCSW documented therapy sessions and treatment plans, this information was not integrated into the facility's records. The sampled residents had various diagnoses, including fibromyalgia, sacral spina bifida, and hemiplegia, and were cognitively intact according to their MDS assessments. Despite receiving regular cognitive behavioral therapy for depression or major depressive disorder, there was no documentation of these services in the facility's medical record system, leaving the records incomplete and inaccessible to the interdisciplinary team.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information based on payroll data to CMS for December 2023. A review of the Payroll Based Journal (PBJ) Staffing Data report revealed that the facility had triggered for four or more days within the quarter with no RN hours and four or more days within the quarter with less than 24 hours/day licensed nursing coverage from December 2, 2023, to December 31, 2023. The facility's policy on Nurse Staffing Information, revised in November 2023, did not address the accurate submission of PBJ data. The Business Office Coordinator, responsible for entering the PBJ data, stated she was unaware of the failure and did not receive any error messages or warnings after submission. The Director of Nursing (DON) also confirmed that she was not aware of any errors and stated that the facility always had adequate nursing staff and 24-hour RN coverage during the period in question. The Administrator confirmed that there was an interface error that resulted in the staffing data not being collected for the specified period. Despite the facility having adequate nursing staff and RN coverage, the data was not submitted accurately to CMS. The Administrator acknowledged that it was ultimately the facility's responsibility to ensure the accuracy of the submitted information, even though no feedback or alerts were received indicating an error. The deficiency was identified through staff interviews and record reviews, highlighting a lapse in the facility's data submission process.
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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.
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Nursing homes near Laurel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurelwood Community Living Center | 0.1 mi | ★★★★★ | 3 | 0 |
| Care Center Of Laurel | 0.2 mi | ★★★★★ | 0 | 0 |
| Jones Co Rest Home | 6 mi | ★★★★★ | 1 | 1 |
| Jasper County Nh | 19 mi | ★★★★★ | 9 | 0 |
| Landmark Of Collins | 23.3 mi | ★★★★★ | 2 | 0 |
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