Cycle 1
Health 2025-04-13 · Fire 2025-04-13
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Richmond Hill, GA
Bryan County Hlth & Rehab Ctr
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
127 Carter St, Richmond Hill, GA
(912) 756-6131
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
100
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-11-01
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
0.21
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,116
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.39
Baseline 18.73% · Performance 20.79% · Measure score 1.39 · Achievement 1.39 · Improvement 0
Healthcare-associated infections
0
Baseline 7.83% · Performance 7.89% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 40.98% · Performance 62.63% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.92
Baseline 3.01 hours · Performance 3.62 hours · Measure score 1.92 · Achievement 1.92 · Improvement 1.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 11.11% · Lower 95% interval 7.18% |
| Discharge to community | 49.21% |
50.57%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 36.84% · Lower 95% interval 35.5% |
| Medicare spending per beneficiary | 1.5 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 81 · Denominator 81 |
| Falls with major injury | 2.47% |
0.77%
1.7 pts worse
|
Numerator 2 · Denominator 81 |
| Discharge self-care score | 30% |
53.69%
23.7 pts worse
|
Numerator 15 · Denominator 50 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 10 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 3 · Denominator 81 · Adjusted rate 3.47% |
| Healthcare-associated infections requiring hospitalization | 7.89% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 9.84% · Lower 95% interval 4.72% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 108 |
| Staff flu vaccination coverage | 11.94% |
42%
30.1 pts worse
|
Numerator 16 · Denominator 134 |
| Discharge function score | 28% |
56.45%
28.5 pts worse
|
Numerator 14 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30.61% |
25.2%
5.4 pts better
|
Numerator 15 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
91.2%
5.7 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.5% · Q3 95.2% · Q4 95.2% · 4Q avg 96.9% |
| 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 | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 1.2% · Q4 2.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.2% |
9.6%
8.6 pts worse
|
11.4%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 21.8% · Q3 11.7% · Q4 13.9% · 4Q avg 18.2% |
| Percentage of long-stay residents who lose too much weight | 14.9% |
5.9%
9 pts worse
|
5.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 17.9% · Q3 14.7% · Q4 10.1% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
20.7%
1.9 pts worse
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 26.8% · Q3 21.1% · Q4 20.0% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.9% |
21.4%
8.5 pts worse
|
16.7%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 32.2% · Q3 30.0% · Q4 28.3% · 4Q avg 29.9% · 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 | 12.9% |
17.9%
5 pts better
|
16.3%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 13.7% · Q3 8.1% · Q4 14.1% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
16.2%
3.9 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 12.3% · Q3 6.2% · Q4 15.6% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.1%
0.2 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 1.8% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.1% |
2.5%
5.6 pts worse
|
1.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.8% · Q3 9.9% · Q4 7.2% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.2% |
16.1%
12.9 pts better
|
19.8%
16.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.7% · Q3 1.2% · Q4 5.9% · 4Q avg 3.2% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
6.2%
1.1 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 6.7% · Q3 6.2% · Q4 7.2% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
80.4%
8.6 pts better
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 83.8% · Q3 93.3% · Q4 100.0% · 4Q avg 89.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.3% |
12.2%
9.1 pts worse
|
12.0%
9.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 21.7% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.4% |
78.2%
0.2 pts better
|
79.7%
1.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
24.2%
1.4 pts better
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 23.9% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-15 · Fire 2022-09-15
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2019-04-26 · Fire 2019-04-26
4 health deficiencies
Top issue: Infection Control (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-05-28
E · Potential for more than minimal harm
2022-09-15
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-10-30
E · Potential for more than minimal harm
2022-09-15
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-10-30
E · Potential for more than minimal harm
2022-09-15
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-10-30
E · Potential for more than minimal harm
2022-09-15
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2022-10-30
E · Potential for more than minimal harm
2022-09-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-10-30
E · Potential for more than minimal harm
2022-09-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-30
E · Potential for more than minimal harm
2022-09-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-10-30
E · Potential for more than minimal harm
2022-09-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-30
D · Potential for more than minimal harm
2022-09-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-30
D · Potential for more than minimal harm
2022-09-15
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-10-30
D · Potential for more than minimal harm
2022-09-15
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-10-30
F · Potential for more than minimal harm
2019-04-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-06-10
F · Potential for more than minimal harm
2019-04-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-06-10
F · Potential for more than minimal harm
2019-04-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-06-10
F · Potential for more than minimal harm
2019-04-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-04-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-04-26
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-04-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-04-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-04-26
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-04-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-06-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-27
F · Potential for more than minimal harm
2025-04-13
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 2025-05-28
F · Potential for more than minimal harm
2025-04-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
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 2025-05-28
D · Potential for more than minimal harm
2025-04-13
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 2025-05-28
D · Potential for more than minimal harm
2025-04-13
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 2025-05-28
D · Potential for more than minimal harm
2025-04-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-28
E · Potential for more than minimal harm
2022-09-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-10-30
E · Potential for more than minimal harm
2022-09-15
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-10-30
D · Potential for more than minimal harm
2022-09-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-10-30
D · Potential for more than minimal harm
2022-09-15
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 2022-10-30
D · Potential for more than minimal harm
2022-09-15
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 2022-10-30
D · Potential for more than minimal harm
2022-09-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-30
D · Potential for more than minimal harm
2022-09-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-10-30
F · Potential for more than minimal harm
2019-04-26
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 2019-06-10
E · Potential for more than minimal harm
2019-04-26
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 2019-06-10
E · Potential for more than minimal harm
2019-04-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-04-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-06-10
Penalties and ownership
What sits behind the stars
Ownership
Cook, Sheila
Operational/Managerial Control · Individual
Cook, Sheila
Corporate Director · Individual
Cook, Sheila
Corporate Officer · Individual
Cook, Terry
Operational/Managerial Control · Individual
Cook, Terry
Corporate Director · Individual
Cook, Terry
Corporate Officer · Individual
Oldfield, Christopher
Operational/Managerial Control · Individual
Stanfield, Dana
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Magnolia Manor Of Midway
Midway, GA
1-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Abercorn Rehabilitation Center
Savannah, GA
3-star overall rating with 3-star inspections with $10,868 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Savannah
Savannah, GA
2-star overall rating with 2-star inspections with $4,963 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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