Cycle 1
Health 2025-07-31 · Fire 2025-07-31
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fort Valley, GA
Church Home Rehabilitation and Healthcare
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2470 Hwy 41 N, Fort Valley, GA
(478) 987-1239
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-11-01
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
0.31
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.42
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
3.03
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.76
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.17
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
0.31
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,593
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9892
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.01
Baseline 19.32% · Performance 20.04% · Measure score 3.01 · Achievement 3.01 · Improvement 0
Healthcare-associated infections
1.44
Baseline 6.62% · Performance 7.41% · Measure score 1.44 · Achievement 1.44 · Improvement 0
Total nurse turnover
5.36
Baseline 60.61% · Performance 41.77% · Measure score 5.36 · Achievement 5.36 · Improvement 4.77
Adjusted total nurse staffing
4.44
Baseline 3.54 hours · Performance 4.34 hours · Measure score 4.44 · Achievement 4.44 · Improvement 3.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.14% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 203 · Observed rate 7.88% · Lower 95% interval 7.31% |
| Discharge to community | 52.4% |
50.57%
1.8 pts better
|
No Different than the National Rate · Eligible stays 190 · Observed rate 51.05% · Lower 95% interval 46.36% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 128 · Denominator 128 |
| Falls with major injury | 1.56% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 128 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 51 · Denominator 102 |
| Discharge mobility score | 63.73% |
50.94%
12.8 pts better
|
Numerator 65 · Denominator 102 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 128 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.41% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 128 · Observed rate 6.25% · Lower 95% interval 4.91% |
| Staff COVID-19 vaccination coverage | 0.83% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 121 |
| Staff flu vaccination coverage | 78.52% |
42%
36.5 pts better
|
Numerator 117 · Denominator 149 |
| Discharge function score | 71.57% |
56.45%
15.1 pts better
|
Numerator 73 · Denominator 102 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 98.72% |
96.28%
2.4 pts better
|
Numerator 77 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 19.35% |
25.2%
5.8 pts worse
|
Numerator 12 · Denominator 62 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.0
1.5 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
91.2%
1.4 pts better
|
93.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.3% · Q3 96.8% · Q4 77.4% · 4Q avg 92.6% |
| 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 | 5.3% |
3.2%
2.1 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.0% · Q3 3.2% · Q4 8.1% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
9.6%
6.8 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 7.5% · Q4 2.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
5.9%
4.7 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 16.7% · Q3 6.5% · Q4 8.3% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
20.7%
6.2 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 18.4% · Q3 12.2% · Q4 14.6% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
21.4%
8.6 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 13.9% · Q3 13.5% · Q4 13.5% · 4Q avg 12.8% · 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 | 20.4% |
17.9%
2.5 pts worse
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.4% |
16.2%
9.2 pts worse
|
14.9%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 29.2% · Q3 15.2% · Q4 24.4% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.9% |
2.5%
3.4 pts worse
|
1.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.8% · Q3 8.5% · Q4 4.8% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
16.1%
10.9 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 28.4% · Q3 30.6% · Q4 24.6% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
6.2%
3.8 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.5% · Q3 2.3% · Q4 1.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
80.4%
10.7 pts better
|
81.7%
9.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 89.2% · Q3 97.3% · Q4 85.1% · 4Q avg 91.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
12.2%
6 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 5.1% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
2.2%
0.2 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.0% |
78.2%
12.8 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
24.2%
0.7 pts better
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 18.8% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-05-05 · Fire 2022-05-05
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2025-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-07-31
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 2025-09-22
D · Potential for more than minimal harm
2025-07-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-07-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-07-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-22
D · Potential for more than minimal harm
2024-03-14
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 2024-04-27
D · Potential for more than minimal harm
2024-03-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-14
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 2024-04-27
D · Potential for more than minimal harm
2024-03-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-31
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 2025-08-22
D · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-22
E · Potential for more than minimal harm
2024-03-14
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 2024-04-27
D · Potential for more than minimal harm
2024-03-14
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 2024-04-27
D · Potential for more than minimal harm
2024-03-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-27
D · Potential for more than minimal harm
2024-03-14
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 2024-04-27
D · Potential for more than minimal harm
2024-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-27
Penalties and ownership
What sits behind the stars
Ownership
Christ's Sanctified Holy Church, Inc.
5% Or Greater Direct Ownership Interest · Organization
Bishop, Charles
Operational/Managerial Control · Individual
Bishop, Charles
Corporate Director · Individual
Bishop, Charles
Corporate Officer · Individual
Bray, Shenita
Operational/Managerial Control · Individual
Collier, Elwood
Operational/Managerial Control · Individual
Collier, Elwood
Corporate Director · Individual
Collier, Elwood
Corporate Officer · Individual
Collier, Jordan
Operational/Managerial Control · Individual
Collier, Jordan
Corporate Director · Individual
Collier, Jordan
Corporate Officer · Individual
Cosby, Mariola
Operational/Managerial Control · Individual
Cosby, Mariola
Corporate Director · Individual
Dent, Susan
Operational/Managerial Control · Individual
Dunbar, Dawn
Operational/Managerial Control · Individual
Dunbar, Dawn
Corporate Officer · Individual
Fuchs, Beth
Operational/Managerial Control · Individual
Glenn, Michael
Operational/Managerial Control · Individual
Greenway, Elizabeth
Operational/Managerial Control · Individual
Johnson, Benita
Operational/Managerial Control · Individual
Johnson, Haley
Operational/Managerial Control · Individual
Padgett, Christy
Operational/Managerial Control · Individual
Patel, Dipenkumar
Operational/Managerial Control · Individual
Reese, Robert
Operational/Managerial Control · Individual
Robuck, Frank
Operational/Managerial Control · Individual
Robuck, Frank
Corporate Director · Individual
Rogers, Tracy
Operational/Managerial Control · Individual
Rogers, Tracy
Corporate Director · Individual
Rogers, Tracy
Corporate Officer · Individual
Smith, Glenn
Operational/Managerial Control · Individual
Smith, Glenn
Corporate Officer · Individual
Smith, Lachantay
Operational/Managerial Control · Individual
Stroupe, Mackenzie
Operational/Managerial Control · Individual
Walker, Randall
Operational/Managerial Control · Individual
Walker, Randall
Corporate Director · Individual
Nearby options
Other facilities in reach
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Summerhill Elderliving Home & Care
Perry, GA
1-star overall rating with 2-star inspections with $105,686 in total fines with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Pruitthealth - The Lodge, LLC
Warner Robins, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Warner Robins Rehabilitation Center
Warner Robins, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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