Cycle 1
Health 2024-11-07 · Fire 2024-11-07
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Savannah, GA
Azalealand Nursing Home
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2040 Colonial Drive, Savannah, GA
(912) 354-2752
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-11-03
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
0.28
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.18
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
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,072
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.83
Baseline 21.16% · Performance 20.12% · Measure score 2.83 · Achievement 2.83 · Improvement 2.02
Healthcare-associated infections
2.38
Baseline 6.28% · Performance 7.12% · Measure score 2.38 · Achievement 2.38 · Improvement 0
Total nurse turnover
3.88
Baseline 38.57% · Performance 47.83% · Measure score 3.88 · Achievement 3.88 · Improvement 0
Adjusted total nurse staffing
0.85
Baseline 3 hours · Performance 3.32 hours · Measure score 0.85 · Achievement 0.85 · Improvement 0.63
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.57% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 13.45% · Lower 95% interval 8.33% |
| Discharge to community | 35.49% |
50.57%
15.1 pts worse
|
Worse than the National Rate · Eligible stays 118 · Observed rate 28.81% · Lower 95% interval 26.83% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.39% |
95.27%
1.1 pts better
|
Numerator 80 · Denominator 83 |
| Falls with major injury | 1.2% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 83 |
| Discharge self-care score | 38.1% |
53.69%
15.6 pts worse
|
Numerator 24 · Denominator 63 |
| Discharge mobility score | 39.68% |
50.94%
11.3 pts worse
|
Numerator 25 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 3.61% |
2.29%
1.3 pts worse
|
Numerator 3 · Denominator 83 · Adjusted rate 2.78% |
| Healthcare-associated infections requiring hospitalization | 7.12% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 80 · Observed rate 6.25% · Lower 95% interval 3.99% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 149 |
| Staff flu vaccination coverage | 24.39% |
42%
17.6 pts worse
|
Numerator 40 · Denominator 164 |
| Discharge function score | 46.03% |
56.45%
10.4 pts worse
|
Numerator 29 · Denominator 63 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 13.64% |
25.2%
11.6 pts worse
|
Numerator 6 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.2
1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
91.2%
6.5 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 98.5% · Q3 98.5% · Q4 98.5% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
95.0%
3.6 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.6% · Q3 4.5% · Q4 6.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
9.6%
6 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.6% · Q3 4.8% · Q4 3.1% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
5.9%
2.3 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.1% · Q3 5.8% · Q4 14.0% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.7% |
20.7%
13 pts worse
|
19.6%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 42.3% · Q3 29.6% · Q4 30.8% · 4Q avg 33.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
21.4%
5.4 pts better
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 14.6% · Q3 22.0% · Q4 16.3% · 4Q avg 16.0% · 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 | 20.1% |
17.9%
2.2 pts worse
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
16.2%
4.4 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 9.3% · Q3 6.4% · Q4 11.1% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
1.1%
1.3 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.9% · Q3 1.0% · Q4 1.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
2.5%
2.3 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.8% · Q3 4.7% · Q4 6.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.5% |
16.1%
6.6 pts better
|
19.8%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 10.1% · Q3 1.7% · Q4 13.0% · 4Q avg 9.5% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
6.2%
2 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 11.5% · Q3 5.0% · Q4 2.3% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
80.4%
16.9 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 100.0% · Q3 98.1% · Q4 94.0% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
12.2%
3.4 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 8.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.5% |
2.2%
4.3 pts worse
|
1.6%
4.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.3% · Q4 5.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
78.2%
20 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.6% |
24.2%
8.6 pts better
|
23.9%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 15.9% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-17 · Fire 2022-11-17
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-01-09 · Fire 2020-01-09
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-22
E · Potential for more than minimal harm
2022-11-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-12-13
E · Potential for more than minimal harm
2022-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-13
E · Potential for more than minimal harm
2022-11-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-13
D · Potential for more than minimal harm
2022-11-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-13
E · Potential for more than minimal harm
2020-01-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-02-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-07
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 2024-12-22
E · Potential for more than minimal harm
2024-11-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-11-07
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-11-07
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 2024-12-22
D · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-22
D · Potential for more than minimal harm
2020-01-09
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2020-02-21
Penalties and ownership
What sits behind the stars
Ownership
Orne, Deborah
5% Or Greater Direct Ownership Interest · Individual
Orne, David
5% Or Greater Direct Ownership Interest · Individual
Parker, David
5% Or Greater Direct Ownership Interest · Individual
Orne, David
W-2 Managing Employee · Individual
Orne, Deborah
Corporate Officer · Individual
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#2
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5-star overall rating with 4-star inspections with 1 recent health deficiencies
#3
Thunderbolt Care Center LLC
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1-star overall rating with 1-star inspections with Special Focus status with $292,548 in total fines with 28 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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