Cycle 1
Health 2025-04-10 · Fire 2025-04-10
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Bainbridge, GA
Bainbridge Health And Rehab
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1155 West College Street, Bainbridge, GA
(229) 243-0931
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Health Communities
Operator or chain grouping
Approved since
1984-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
40 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
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
0.66
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.24
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
2.85
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,270
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.07
Baseline 18.35% · Performance 18.16% · Measure score 7.07 · Achievement 7.07 · Improvement 0.95
Healthcare-associated infections
2.08
Baseline 6.62% · Performance 7.21% · Measure score 2.08 · Achievement 2.08 · Improvement 0
Total nurse turnover
2.94
Baseline 29.69% · Performance 51.67% · Measure score 2.94 · Achievement 2.94 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.80 hours · Performance 2.80 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 6.41% · Lower 95% interval 6.7% |
| Discharge to community | 46.48% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 40% · Lower 95% interval 34.37% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.08% |
95.27%
2.8 pts better
|
Numerator 51 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 52.17% |
53.69%
1.5 pts worse
|
Numerator 12 · Denominator 23 |
| Discharge mobility score | 52.17% |
50.94%
1.2 pts better
|
Numerator 12 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 52 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.21% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | 43.24% |
42%
1.2 pts better
|
Numerator 32 · Denominator 74 |
| Discharge function score | 65.22% |
56.45%
8.8 pts better
|
Numerator 15 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 69.23% |
25.2%
44 pts better
|
Numerator 18 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.2
0.9 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
91.2%
7.5 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.2% · Q3 98.2% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.0% |
95.0%
5 pts worse
|
95.5%
5.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
9.6%
7.1 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.1% · Q3 2.0% · Q4 1.9% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.9%
0.6 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 8.0% · Q3 6.0% · Q4 5.9% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
20.7%
8.4 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 11.3% · Q3 13.5% · Q4 9.8% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
21.4%
16.2 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 7.9% · Q3 5.4% · Q4 2.4% · 4Q avg 5.2% · 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 | 34.9% |
17.9%
17 pts worse
|
16.3%
18.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 16.4% · 4Q avg 34.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.3% |
16.2%
7.1 pts worse
|
14.9%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.0% · Q2 12.5% · Q3 23.9% · Q4 20.0% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.1%
1.7 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 1.7% · Q4 5.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.5%
0.7 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 5.5% · Q4 3.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.4% |
16.1%
1.7 pts better
|
19.8%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 12.3% · Q3 19.1% · Q4 11.5% · 4Q avg 14.4% |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
6.2%
3 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 10.5% · Q3 7.8% · Q4 9.1% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.1% |
80.4%
5.7 pts better
|
81.7%
4.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 95.2% · Q3 80.0% · Q4 77.0% · 4Q avg 86.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
12.2%
2.7 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 9.8% · Expected 11.4% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 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 | 84.1% |
78.2%
5.9 pts better
|
79.7%
4.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
24.2%
2.5 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 26.8% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-27 · Fire 2022-07-27
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-04-18 · Fire 2019-04-18
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-25
D · Potential for more than minimal harm
2025-04-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-25
D · Potential for more than minimal harm
2022-07-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-08
D · Potential for more than minimal harm
2022-07-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-08
F · Potential for more than minimal harm
2019-04-18
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-05-18
F · Potential for more than minimal harm
2019-04-18
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-05-18
F · Potential for more than minimal harm
2019-04-18
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-05-18
F · Potential for more than minimal harm
2019-04-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-05-18
F · Potential for more than minimal harm
2019-04-18
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-05-18
F · Potential for more than minimal harm
2019-04-18
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-05-18
E · Potential for more than minimal harm
2019-04-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-05-18
D · Potential for more than minimal harm
2019-04-18
K231 · Egress Deficiencies
Fire Safety
Provide large enough exits.
Corrected 2019-05-18
D · Potential for more than minimal harm
2019-04-18
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2019-05-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-10
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 2025-05-25
E · Potential for more than minimal harm
2025-04-10
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 2025-05-25
E · Potential for more than minimal harm
2025-04-10
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2025-05-25
D · Potential for more than minimal harm
2025-04-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-25
D · Potential for more than minimal harm
2025-04-10
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-05-25
D · Potential for more than minimal harm
2025-04-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-25
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-25
D · Potential for more than minimal harm
2024-09-26
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-11-10
E · Potential for more than minimal harm
2019-04-18
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 2019-05-18
Penalties and ownership
What sits behind the stars
Ownership
Gbd LLC
5% Or Greater Direct Ownership Interest · Organization
Barnes, Michelle
W-2 Managing Employee · Individual
Barres, LLC
5% Or Greater Indirect Ownership Interest · Organization
Crino, Bryan
5% Or Greater Indirect Ownership Interest · Individual
Feuer, Scott
5% Or Greater Indirect Ownership Interest · Individual
Lindeman, Stuart
5% Or Greater Indirect Ownership Interest · Individual
Lindeman, Stuart
Corporate Officer · Individual
Mission Health Of Georgia, LLC
Operational/Managerial Control · Organization
Passero, Joseph
5% Or Greater Indirect Ownership Interest · Individual
T And C Capital Assets, LLC
5% Or Greater Indirect Ownership Interest · Organization
Windward Health Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Yoakum, Jamie
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Memorial Manor Nursing Home
Bainbridge, GA
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Pinewood Health and Rehabilitation
Whigham, GA
1-star overall rating with 1-star inspections with Special Focus status with $210,094 in total fines with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Seminole Manor Nursing Home
Donalsonville, GA
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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