Cycle 1
Health 2025-02-26 · Fire 2025-02-26
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Macon, GA
Bolingreen Health And Rehabilitation
2-star overall rating with 2-star inspections with $16,800 in total fines with 5 recent health deficiencies
529 Bolingreen Drive, Macon, GA
(478) 477-1720
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1989-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
48 facilities
Chain averages 4 overall / 4 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
0.65
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.50
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
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,787
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.71% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.03
Baseline 6.09% · Performance 7.53% · Measure score 1.03 · Achievement 1.03 · Improvement 0
Total nurse turnover
2.14
Baseline 62.30% · Performance 54.93% · Measure score 2.14 · Achievement 2.14 · Improvement 1.47
Adjusted total nurse staffing
2.94
Baseline 3.22 hours · Performance 3.92 hours · Measure score 2.94 · Achievement 2.94 · Improvement 2.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.32% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 14% · Lower 95% interval 8.01% |
| Discharge to community | 33.89% |
50.57%
16.7 pts worse
|
Worse than the National Rate · Eligible stays 56 · Observed rate 21.43% · Lower 95% interval 24.08% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.62% |
95.27%
1.6 pts worse
|
Numerator 44 · Denominator 47 |
| Falls with major injury | 2.13% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 47 |
| Discharge self-care score | 11.11% |
53.69%
42.6 pts worse
|
Numerator 4 · Denominator 36 |
| Discharge mobility score | 19.44% |
50.94%
31.5 pts worse
|
Numerator 7 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 10.64% |
2.29%
8.4 pts worse
|
Numerator 5 · Denominator 47 · Adjusted rate 9.42% |
| Healthcare-associated infections requiring hospitalization | 7.53% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 10.42% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 3.16% |
8.2%
5 pts worse
|
Numerator 3 · Denominator 95 |
| Staff flu vaccination coverage | 51.58% |
42%
9.6 pts better
|
Numerator 49 · Denominator 95 |
| Discharge function score | 19.44% |
56.45%
37 pts worse
|
Numerator 7 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 37.5% |
25.2%
12.3 pts better
|
Numerator 9 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.1% |
91.2%
2.1 pts worse
|
93.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.6% · Q2 82.4% · Q3 90.4% · Q4 97.1% · 4Q avg 89.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
95.0%
2.2 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.2%
2.6 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 4.4% · Q3 4.1% · Q4 7.4% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 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 who lose too much weight | 4.3% |
5.9%
1.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 7.9% · Q3 2.9% · Q4 4.5% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
20.7%
7.5 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 11.1% · Q3 15.9% · Q4 13.6% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.0% |
21.4%
7.6 pts worse
|
16.7%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 25.0% · Q3 32.2% · Q4 32.0% · 4Q avg 29.0% · 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 | 14.2% |
17.9%
3.7 pts better
|
16.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 4.8% · Q3 19.2% · Q4 17.4% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
16.2%
0.8 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 21.8% · Q3 11.5% · Q4 14.5% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.1%
0.2 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 1.4% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.5%
1.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.3% |
16.1%
5.8 pts better
|
19.8%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 8.1% · Q3 5.6% · Q4 12.8% · 4Q avg 10.3% |
| Percentage of long-stay residents with pressure ulcers | 12.7% |
6.2%
6.5 pts worse
|
5.1%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 16.1% · Q3 14.0% · Q4 8.4% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 51.1% |
80.4%
29.3 pts worse
|
81.7%
30.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 50.0% · Q3 57.6% · Q4 70.5% · 4Q avg 51.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
12.2%
5.7 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 7.1% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
2.2%
0.9 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.1% · Q3 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.3% |
78.2%
19.9 pts worse
|
79.7%
21.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
24.2%
5.4 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 21.4% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-04 · Fire 2024-02-04
13 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-02-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-04
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-03-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-26
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 2025-04-11
F · Potential for more than minimal harm
2025-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
F · Potential for more than minimal harm
2025-02-26
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-26
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 2025-04-11
D · Potential for more than minimal harm
2025-02-26
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-04-11
G · Actual harm
2024-02-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-01
G · Actual harm
2024-02-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-01
F · Potential for more than minimal harm
2024-02-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-04
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-04
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 2024-03-01
D · Potential for more than minimal harm
2024-02-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-04
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-04
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-04
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 2024-03-01
D · Potential for more than minimal harm
2024-02-04
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-01-12
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 2023-02-26
D · Potential for more than minimal harm
2023-01-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-26
D · Potential for more than minimal harm
2023-01-12
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-02-26
Penalties and ownership
What sits behind the stars
$4,017
2024-02-04
Fine
Fine · fine $4,017
Fine
$6,391
2024-02-04
Fine
Fine · fine $6,391
Fine
$6,392
2024-02-04
Fine
Fine · fine $6,392
Fine
Ownership
Community Health Systems Inc
5% Or Greater Indirect Ownership Interest · Organization
Health Scholarships Inc
5% Or Greater Direct Ownership Interest · Organization
Cable, Paul
Corporate Director · Individual
Clinical Services Inc
Operational/Managerial Control · Organization
Davis, Gregory
Operational/Managerial Control · Individual
Dennis, Kathryn
Corporate Director · Individual
Gerard, Jason
Operational/Managerial Control · Individual
Medley, Michelle
Operational/Managerial Control · Individual
Nichols, Joseph
Corporate Director · Individual
Patel, Maulikkumar
Operational/Managerial Control · Individual
Rollins, Ronnie
Corporate Director · Individual
Street, Amy
Operational/Managerial Control · Individual
Wall, Joseph
Corporate Director · Individual
Warnock, Ralph
Corporate Director · Individual
Nearby options
Other facilities in reach
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Zebulon Park Health And Rehabilitation
Macon, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Carlyle Place
Macon, GA
1-star overall rating with 1-star inspections with $105,498 in total fines with 2 recent health deficiencies
#3
Pruitthealth - Peake
Macon, GA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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