Cycle 1
Health 2025-02-13 · Fire 2025-02-13
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Macon, GA
Cherry Blossom Health And Rehabilitation
3-star overall rating with 3-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3520 Kenneth Drive, Macon, GA
(478) 781-7553
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
58
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1998-02-01
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
0.41
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.34
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,343
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
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
0
Baseline 47.92% · Performance 62.50% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.27
Baseline 3.51 hours · Performance 3.44 hours · Measure score 1.27 · Achievement 1.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · 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 143 |
| Staff flu vaccination coverage | 52.88% |
42%
10.9 pts better
|
Numerator 55 · Denominator 104 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
91.2%
2.9 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 84.2% · Q2 96.3% · Q3 98.2% · Q4 98.2% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
95.0%
1.6 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.2%
2.7 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.9%
1.1 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 9.8% · Q3 7.4% · Q4 1.8% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.1% |
20.7%
7.4 pts worse
|
19.6%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 30.2% · Q3 27.3% · Q4 23.6% · 4Q avg 28.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.2% |
21.4%
1.2 pts better
|
16.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 21.4% · Q3 18.2% · Q4 20.0% · 4Q avg 20.2% · 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 | 13.6% |
17.9%
4.3 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
16.2%
8.3 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 14.3% · Q3 5.9% · Q4 0.0% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.1%
0.4 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.5%
1.6 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
16.1%
2.5 pts worse
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 20.3% · Q3 18.3% · Q4 21.8% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.2%
About the same
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.9% · Q3 7.4% · Q4 7.8% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.7% |
80.4%
10.7 pts worse
|
81.7%
12 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 61.9% · 4Q avg 69.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
2.2%
1.2 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.6% |
78.2%
14.6 pts worse
|
79.7%
16.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-21 · Fire 2023-09-21
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-03-17 · Fire 2022-03-17
1 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
E · Potential for more than minimal harm
2025-02-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-13
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 2025-03-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-13
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 2025-03-12
E · Potential for more than minimal harm
2023-09-21
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-21
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 2023-11-05
D · Potential for more than minimal harm
2023-09-21
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 2023-11-05
D · Potential for more than minimal harm
2023-09-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-21
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 2023-11-05
D · Potential for more than minimal harm
2023-09-21
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 2023-11-05
D · Potential for more than minimal harm
2023-09-21
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 2023-11-05
D · Potential for more than minimal harm
2023-09-21
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-21
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-21
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 2023-11-05
D · Potential for more than minimal harm
2023-09-21
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-21
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-21
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-09-21
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-11-05
D · Potential for more than minimal harm
2022-03-17
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-04-19
Penalties and ownership
What sits behind the stars
Ownership
Community Health Systems Inc
5% Or Greater Indirect Ownership Interest · Organization
B.f.l.d., Inc.
5% Or Greater Direct Ownership Interest · Organization
Clinical Services Inc
Operational/Managerial Control · Organization
Davis, Gregory
Operational/Managerial Control · Individual
Health Systems Facilities Inc
5% Or Greater Direct Ownership Interest · Organization
Holleman, Linton
Operational/Managerial Control · Individual
Mosley, Jennifer
Operational/Managerial Control · Individual
Patel, Maulikkumar
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Pruitthealth - Macon
Macon, GA
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Archway Transitional Care Center
Macon, GA
2-star overall rating with 1-star inspections with abuse icon flag with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Medical Management Health And Rehab Center
Macon, GA
3-star overall rating with 4-star inspections with $41,316 in total fines with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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