Cycle 1
Health 2025-09-21 · Fire 2025-09-21
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Macon, GA
Carlyle Place
1-star overall rating with 1-star inspections with $105,498 in total fines with 2 recent health deficiencies
5300 Zebulon Road, Macon, GA
(478) 405-4500
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
26
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-12-09
CMS approved date
Coverage
Medicare
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
0.54
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
2.09
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
5.34
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
2.64
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.41
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.45
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
0.57
CMS adjusted RN staffing hours
Adjusted total hours
5.62
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
419
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
70.32
Composite VBP score used to determine payment impact.
Payment multiplier
1.0225
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.06
Baseline 71.11% · Performance 50.00% · Measure score 4.06 · Achievement 3.35 · Improvement 4.06
Adjusted total nurse staffing
10
Baseline 6.23 hours · Performance 5.85 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.28% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 6.94% |
| Discharge to community | 36.68% |
50.57%
13.9 pts worse
|
Worse than the National Rate · Eligible stays 37 · Observed rate 29.73% · Lower 95% interval 26.14% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 0% |
95.27%
95.3 pts worse
|
Numerator 0 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | 20% |
53.69%
33.7 pts worse
|
Numerator 4 · Denominator 20 |
| Discharge mobility score | 15% |
50.94%
35.9 pts worse
|
Numerator 3 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 84 |
| Staff flu vaccination coverage | 97.3% |
42%
55.3 pts better
|
Numerator 72 · Denominator 74 |
| Discharge function score | 35% |
56.45%
21.5 pts worse
|
Numerator 7 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
91.2%
5.3 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q4 85.0% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
95.0%
2.7 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.2%
0.3 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q4 5.0% · 4Q avg 3.5% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.9%
5.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.4% |
20.7%
4.7 pts worse
|
19.6%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
21.4%
10.3 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
16.2%
9.2 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.7% |
16.1%
9.4 pts better
|
19.8%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 0.0% · 4Q avg 6.7% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
6.2%
1.9 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 13.8% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.3% |
80.4%
12.1 pts worse
|
81.7%
13.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.0% · Q2 52.0% · Q3 72.4% · Q4 73.8% · 4Q avg 68.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
12.2%
3.4 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 7.1% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
2.2%
0.3 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 5.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.5% |
78.2%
16.7 pts worse
|
79.7%
18.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.5% |
24.2%
7.3 pts worse
|
23.9%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.5% · Observed 21.4% · Expected 16.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-25 · Fire 2024-08-25
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-30 · Fire 2023-04-30
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
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
2024-08-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-25
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2024-09-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-21
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 2025-11-04
D · Potential for more than minimal harm
2025-09-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-11-04
F · Potential for more than minimal harm
2024-08-25
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 2024-09-16
D · Potential for more than minimal harm
2024-08-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-16
K · Immediate jeopardy
2024-04-19
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-06-07
K · Immediate jeopardy
2024-04-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-06-07
J · Immediate jeopardy
2024-04-19
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-06-07
J · Immediate jeopardy
2024-04-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-07
J · Immediate jeopardy
2024-04-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-07
F · Potential for more than minimal harm
2023-04-30
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 2023-06-14
E · Potential for more than minimal harm
2023-04-30
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 2023-06-14
D · Potential for more than minimal harm
2023-04-30
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-04-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-04-30
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 2023-06-14
Penalties and ownership
What sits behind the stars
$105,498
2024-04-19
Fine
Fine · fine $105,498
Fine
$0
2024-04-19
Payment Denial
Payment Denial · denial start 2024-04-25 · 43 days
43 day denial
Ownership
Navicent Health Inc
5% Or Greater Direct Ownership Interest · Organization
The Charlotte-Mecklenburg Hospital Authority
5% Or Greater Indirect Ownership Interest · Organization
Advocate Health Inc
Operational/Managerial Control · Organization
Ah Georgia Inc
5% Or Greater Indirect Ownership Interest · Organization
Atrium Health Inc
Operational/Managerial Control · Organization
Baralatei, Florence
W-2 Managing Employee · Individual
Biek, David
Corporate Director · Individual
Cannaday, Troy
W-2 Managing Employee · Individual
Collier, Ronnie
Corporate Director · Individual
Finley, Delvecchio
Corporate Officer · Individual
Gheesling, Angie
Corporate Director · Individual
Habersham, Myrtle
Corporate Director · Individual
Habersham, Myrtle
Corporate Officer · Individual
Kimsey, Carol
Corporate Director · Individual
Koplin, Henry
Corporate Director · Individual
Purdue, Adrienne
Corporate Officer · Individual
Scott, Wade
Corporate Director · Individual
Shrewsbury, Kimberly
Corporate Officer · Individual
Simpson, Theron
Corporate Director · Individual
Snyder, Erin
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
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
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
#3
Bolingreen Health And Rehabilitation
Macon, GA
2-star overall rating with 2-star inspections with $16,800 in total fines with 5 recent health deficiencies
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