Cycle 1
Health 2024-12-08 · Fire 2024-12-08
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Milledgeville, GA
Atrium Health Navicent Baldwin
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
821 North Cobb Street, Milledgeville, GA
(478) 454-3649
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
15
Certified beds
Average residents
10
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-04-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.63
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.69
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
6.39
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
4.32
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
7.00
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
3.52
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
2.74
CMS adjusted RN staffing hours
Adjusted total hours
6.65
CMS adjusted total nurse staffing hours
Case-mix index
1.31
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
3,548
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9968
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.24
Baseline 20.83% · Performance 19.93% · Measure score 3.24 · Achievement 3.24 · Improvement 1.86
Healthcare-associated infections
7.58
Baseline 6.35% · Performance 5.57% · Measure score 7.58 · Achievement 7.58 · Improvement 5.25
Total nurse turnover
2.33
Baseline 35.71% · Performance 54.17% · Measure score 2.33 · Achievement 2.33 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.52% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 9.17% · Lower 95% interval 8.07% |
| Discharge to community | 67.13% |
50.57%
16.6 pts better
|
Better than the National Rate · Eligible stays 104 · Observed rate 70.19% · Lower 95% interval 58.54% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.21% |
95.27%
2.9 pts better
|
Numerator 55 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 76.09% |
53.69%
22.4 pts better
|
Numerator 35 · Denominator 46 |
| Discharge mobility score | 36.96% |
50.94%
14 pts worse
|
Numerator 17 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.79% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 56 · Adjusted rate 2.22% |
| Healthcare-associated infections requiring hospitalization | 5.57% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 0% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 16 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 17 · Denominator 17 |
| Discharge function score | 54.35% |
56.45%
2.1 pts worse
|
Numerator 25 · Denominator 46 |
| Transfer of health information to provider | 68.75% |
95.95%
27.2 pts worse
|
Numerator 22 · Denominator 32 |
| Transfer of health information to patient | 91.67% |
96.28%
4.6 pts worse
|
Numerator 22 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 3.85% |
25.2%
21.3 pts worse
|
Numerator 1 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
80.4%
16.6 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 95.2% · Q3 97.7% · Q4 100.0% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
12.2%
0.9 pts better
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 10.2% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
2.2%
1.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
78.2%
16.2 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
24.2%
7.6 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 12.2% · Expected 17.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-12 · Fire 2023-11-12
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-10-02 · Fire 2022-10-02
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2024-12-08
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-01-20
F · Potential for more than minimal harm
2024-12-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-01-20
F · Potential for more than minimal harm
2024-12-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-20
F · Potential for more than minimal harm
2024-12-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-20
D · Potential for more than minimal harm
2023-11-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-22
Inspection history
Recent health citations
Penalties and ownership
What sits behind the stars
Ownership
Navicent Health Inc
5% Or Greater Direct Ownership Interest · Organization
Advocate Health Inc
Operational/Managerial Control · Organization
Ah Georgia Inc
5% Or Greater Indirect Ownership Interest · Organization
Atrium Health Inc
Operational/Managerial Control · Organization
Coleman, Lucretia
Corporate Officer · Individual
Filimon, Dragos
Operational/Managerial Control · Individual
Ransom, Meredith
Operational/Managerial Control · Individual
Snyder, Erin
Corporate Officer · Individual
The Charlotte-Mecklenburg Hospital Authority
5% Or Greater Indirect Ownership Interest · Organization
Thomas, Mollie
Corporate Officer · Individual
Wheeler, Philip
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Chaplinwood Nursing Home
Milledgeville, GA
3-star overall rating with 3-star inspections with $7,901 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Green Acres Health And Rehabilitation
Milledgeville, GA
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Bostick Nursing Center
Milledgeville, GA
1-star overall rating with 1-star inspections with $546,749 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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