Cycle 1
Health 2025-12-04 · Fire 2025-12-04
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Waycross, GA
Baptist Village, Inc.
5-star overall rating with 5-star inspections with $10,218 in total fines with 7 fire-safety deficiencies in the latest cycle
2650 Carswell Ave, Waycross, GA
(912) 283-7050
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
254
Certified beds
Average residents
170
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-09-01
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
0.35
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
3.30
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.91
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.37
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,116
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9881
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.04% · Performance 22.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.66
Baseline 6.73% · Performance 6.74% · Measure score 3.66 · Achievement 3.66 · Improvement 0
Total nurse turnover
5.14
Baseline 45.05% · Performance 42.66% · Measure score 5.14 · Achievement 5.14 · Improvement 0.68
Adjusted total nurse staffing
4.78
Baseline 3.77 hours · Performance 4.44 hours · Measure score 4.78 · Achievement 4.78 · Improvement 2.81
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.57% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 213 · Observed rate 7.51% · Lower 95% interval 7.08% |
| Discharge to community | 46.17% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 147 · Observed rate 42.86% · Lower 95% interval 38.4% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.1% |
95.27%
3.8 pts better
|
Numerator 110 · Denominator 111 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 111 |
| Discharge self-care score | 38.16% |
53.69%
15.5 pts worse
|
Numerator 29 · Denominator 76 |
| Discharge mobility score | 43.42% |
50.94%
7.5 pts worse
|
Numerator 33 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 4.5% |
2.29%
2.2 pts worse
|
Numerator 5 · Denominator 111 · Adjusted rate 3.47% |
| Healthcare-associated infections requiring hospitalization | 6.74% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 5.56% · Lower 95% interval 4.03% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 337 |
| Staff flu vaccination coverage | 22.4% |
42%
19.6 pts worse
|
Numerator 127 · Denominator 567 |
| Discharge function score | 51.32% |
56.45%
5.1 pts worse
|
Numerator 39 · Denominator 76 |
| Transfer of health information to provider | 77.14% |
95.95%
18.8 pts worse
|
Numerator 27 · Denominator 35 |
| Transfer of health information to patient | 94.59% |
96.28%
1.7 pts worse
|
Numerator 35 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 27.12% |
25.2%
1.9 pts better
|
Numerator 16 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.2
About the same
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.8 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.2%
8.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 100.0% · Q3 100.0% · Q4 99.4% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.4% |
95.0%
4.4 pts better
|
95.5%
3.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.2%
1.7 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 6.0% · Q3 4.9% · Q4 4.9% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
9.6%
6.7 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 3.4% · Q3 2.7% · Q4 4.7% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.9%
About the same
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.0% · Q3 8.3% · Q4 3.0% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.0% |
20.7%
0.3 pts worse
|
19.6%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.6% · Q3 17.9% · Q4 17.0% · 4Q avg 21.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.1% |
21.4%
6.7 pts worse
|
16.7%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 26.8% · Q3 28.7% · Q4 29.8% · 4Q avg 28.1% · 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 | 13.8% |
17.9%
4.1 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 16.6% · Q3 14.7% · Q4 11.8% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
16.2%
4 pts better
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 14.4% · Q3 12.9% · Q4 7.3% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.1%
0.9 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.5%
About the same
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.9% · Q3 1.9% · Q4 1.9% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
16.1%
3.5 pts worse
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 21.8% · Q3 21.2% · Q4 10.2% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
6.2%
2 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.8% · Q3 4.5% · Q4 3.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
80.4%
17.4 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.1% · Q3 98.1% · Q4 96.4% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
12.2%
1.8 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 9.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.2%
0.7 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 2.7% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
78.2%
13.8 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
24.2%
0.9 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 23.8% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2024-09-19
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-04-27 · Fire 2023-04-27
3 health deficiencies
Top issue: Infection Control (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-04
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2026-01-17
E · Potential for more than minimal harm
2025-12-04
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-01-17
D · Potential for more than minimal harm
2025-12-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-01-17
D · Potential for more than minimal harm
2025-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-17
D · Potential for more than minimal harm
2025-12-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-17
D · Potential for more than minimal harm
2025-12-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-17
D · Potential for more than minimal harm
2025-12-04
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2026-01-17
D · Potential for more than minimal harm
2024-09-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-03
F · Potential for more than minimal harm
2023-04-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-11
F · Potential for more than minimal harm
2023-04-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-11
F · Potential for more than minimal harm
2023-04-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-11
F · Potential for more than minimal harm
2023-04-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-04-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-09-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-03
F · Potential for more than minimal harm
2023-04-27
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-11
Penalties and ownership
What sits behind the stars
$4,017
2024-09-19
Fine
Fine · fine $4,017
Fine
$6,201
2023-04-27
Fine
Fine · fine $6,201
Fine
Ownership
Executive Committee Of The Baptist Convention Of The State Of Georgia
5% Or Greater Direct Ownership Interest · Organization
Clough, Archie
Corporate Officer · Individual
Clough, Archie
W-2 Managing Employee · Individual
Mathison, John
Corporate Officer · Individual
Stipe, Summer
Corporate Officer · Individual
Sweat, Holli
W-2 Managing Employee · Individual
Nearby options
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#2
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2-star overall rating with 2-star inspections with $9,620 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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