Cycle 1
Health 2025-04-17 · Fire 2025-04-17
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Nashville, GA
Berrien Oaks Nursing And Rehab Center
1-star overall rating with 3-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
405 Laurel Street, Nashville, GA
(229) 543-7335
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eliyahu Mirlis
Operator or chain grouping
Approved since
1987-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 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
0.31
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.72
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
2.87
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.71
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
2.65
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,687
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
1.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 23.76% · Performance 24.83% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.68
Baseline 11.62% · Performance 10.84% · Measure score 0.68 · Achievement 0 · Improvement 0.68
Total nurse turnover
0
Baseline 38.67% · Performance 100.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.22 hours · Performance 2.31 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 12.12% · Lower 95% interval 7.69% |
| Discharge to community | 35.1% |
50.57%
15.5 pts worse
|
Worse than the National Rate · Eligible stays 60 · Observed rate 26.67% · Lower 95% interval 26.3% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 88 · Denominator 88 |
| Falls with major injury | 1.14% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 88 |
| Discharge self-care score | 44.68% |
53.69%
9 pts worse
|
Numerator 21 · Denominator 47 |
| Discharge mobility score | 51.06% |
50.94%
0.1 pts better
|
Numerator 24 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 3.41% |
2.29%
1.1 pts worse
|
Numerator 3 · Denominator 88 · Adjusted rate 2.67% |
| Healthcare-associated infections requiring hospitalization | 10.84% |
7.12%
3.7 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 17.19% · Lower 95% interval 6.45% |
| Staff COVID-19 vaccination coverage | 0.87% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 115 |
| Staff flu vaccination coverage | 11.22% |
42%
30.8 pts worse
|
Numerator 22 · Denominator 196 |
| Discharge function score | 51.06% |
56.45%
5.4 pts worse
|
Numerator 24 · Denominator 47 |
| Transfer of health information to provider | 96.77% |
95.95%
0.8 pts better
|
Numerator 30 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.2
0.4 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
2.0
2.2 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 3.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.2%
8.2 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 98.9% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.2%
1.9 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.5% · Q3 4.7% · Q4 8.8% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.4% |
9.6%
6.8 pts worse
|
11.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 7.1% · Q3 17.9% · Q4 38.5% · 4Q avg 16.4% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.9%
0.6 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 6.5% · Q3 12.0% · Q4 6.3% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
20.7%
2.2 pts better
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 17.9% · Q3 15.7% · Q4 23.0% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.9% |
21.4%
14.5 pts worse
|
16.7%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 33.3% · Q3 35.4% · Q4 38.2% · 4Q avg 35.9% · 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 | 11.0% |
17.9%
6.9 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 7.4% · Q3 13.6% · Q4 6.5% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
16.2%
4.9 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 15.8% · Q3 12.3% · Q4 5.1% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.1%
0.5 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.0% · Q3 1.0% · Q4 2.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.5%
0.3 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 6.4% · Q4 3.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.4% |
16.1%
3.7 pts better
|
19.8%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 9.3% · Q3 6.5% · Q4 5.0% · 4Q avg 12.4% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
6.2%
0.5 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.0% · Q3 6.1% · Q4 7.5% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
80.4%
6.3 pts better
|
81.7%
5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 87.1% · Q3 87.9% · Q4 85.7% · 4Q avg 86.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.7% |
12.2%
7.5 pts worse
|
12.0%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 18.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
2.2%
3.2 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.1% · Q3 6.9% · Q4 2.9% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.1% |
78.2%
17.1 pts worse
|
79.7%
18.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.0% |
24.2%
6.8 pts worse
|
23.9%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.0% · Observed 28.4% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-04-07 · Fire 2022-04-07
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
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
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-17
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
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 2025-06-03
D · Potential for more than minimal harm
2025-04-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-03
F · Potential for more than minimal harm
2024-02-01
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-17
F · Potential for more than minimal harm
2024-02-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-17
F · Potential for more than minimal harm
2024-02-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-17
E · Potential for more than minimal harm
2024-02-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-17
D · Potential for more than minimal harm
2024-02-01
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 2024-03-17
D · Potential for more than minimal harm
2024-02-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-17
E · Potential for more than minimal harm
2025-04-17
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 2025-06-01
D · Potential for more than minimal harm
2025-04-17
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 2025-06-01
D · Potential for more than minimal harm
2025-04-17
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-04-17
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 2025-06-01
D · Potential for more than minimal harm
2025-04-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-01
F · Potential for more than minimal harm
2024-02-01
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 2024-03-17
F · Potential for more than minimal harm
2024-02-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-17
E · Potential for more than minimal harm
2024-02-01
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-17
D · Potential for more than minimal harm
2024-02-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-17
D · Potential for more than minimal harm
2022-04-07
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 2022-05-22
Penalties and ownership
What sits behind the stars
Ownership
Mirlis, Eliyahu
5% Or Greater Direct Ownership Interest · Individual
Inzelbuch, Azriel
5% Or Greater Direct Ownership Interest · Individual
Nash, William
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Southwell Health And Rehabilitation
Adel, GA
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Sgmc Health Villa
Lakeland, GA
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Harborview Tifton
Tifton, GA
1-star overall rating with 1-star inspections with $22,032 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
Jump out