Cycle 1
Health 2024-08-14 · Fire 2024-08-14
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Moultrie, GA
Colquitt Regional Senior Care & Rehabilitation
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
101 Cobblestone Trace Se, Moultrie, GA
(229) 985-3637
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
56
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-05-30
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
0.57
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.57
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.30
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
4.34
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,031
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9997
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.98
Baseline 25.12% · Performance 20.69% · Measure score 4.98 · Achievement 1.60 · Improvement 4.98
Healthcare-associated infections
4.26
Baseline 9.02% · Performance 7.11% · Measure score 4.26 · Achievement 2.43 · Improvement 4.26
Total nurse turnover
7.26
Baseline 42.55% · Performance 34.00% · Measure score 7.26 · Achievement 7.26 · Improvement 4.33
Adjusted total nurse staffing
2.03
Baseline 3.17 hours · Performance 3.66 hours · Measure score 2.03 · Achievement 2.03 · Improvement 1.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.85% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 160 · Observed rate 15.63% · Lower 95% interval 9.47% |
| Discharge to community | 61.12% |
50.57%
10.5 pts better
|
Better than the National Rate · Eligible stays 146 · Observed rate 57.53% · Lower 95% interval 53.47% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.06% |
95.27%
3.8 pts better
|
Numerator 105 · Denominator 106 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 106 |
| Discharge self-care score | 42.5% |
53.69%
11.2 pts worse
|
Numerator 34 · Denominator 80 |
| Discharge mobility score | 53.75% |
50.94%
2.8 pts better
|
Numerator 43 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 106 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.11% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 6.06% |
8.2%
2.1 pts worse
|
Numerator 4 · Denominator 66 |
| Staff flu vaccination coverage | 52.81% |
42%
10.8 pts better
|
Numerator 47 · Denominator 89 |
| Discharge function score | 65% |
56.45%
8.5 pts better
|
Numerator 52 · Denominator 80 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 64 · Denominator 64 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 8.62% |
25.2%
16.6 pts worse
|
Numerator 5 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.1 · Expected 2.5 · 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 1.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 5.4% |
3.2%
2.2 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 4.4% · Q4 8.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
9.6%
9 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.9%
2 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.9% · Q3 2.9% · Q4 5.3% · 4Q avg 3.9% |
| 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 20.9% · Q2 23.3% · Q3 21.6% · Q4 24.4% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.8% |
21.4%
11.4 pts worse
|
16.7%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 34.4% · Q3 34.5% · Q4 33.3% · 4Q avg 32.8% · 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 | 18.1% |
17.9%
0.2 pts worse
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
16.2%
2 pts better
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 9.8% · Q3 17.1% · Q4 23.1% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.1%
About the same
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.5%
0.9 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.4% · Q3 4.8% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.0% |
16.1%
8.1 pts better
|
19.8%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 2.7% · Q3 8.1% · Q4 13.7% · 4Q avg 8.0% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
6.2%
0.3 pts better
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.0% · Q3 6.7% · Q4 7.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
80.4%
18.5 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.9% · Q3 100.0% · Q4 97.8% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
12.2%
1.7 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 9.6% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
2.2%
1.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
78.2%
16.6 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.0% |
24.2%
2.8 pts worse
|
23.9%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.0% · Observed 23.1% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-18 · Fire 2022-08-18
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-09-06 · Fire 2019-09-06
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-09-20
F · Potential for more than minimal harm
2024-08-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-20
F · Potential for more than minimal harm
2022-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-03
D · Potential for more than minimal harm
2019-09-06
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2019-10-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-14
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 2024-09-16
D · Potential for more than minimal harm
2024-08-14
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-16
D · Potential for more than minimal harm
2022-08-18
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 2022-10-10
D · Potential for more than minimal harm
2022-08-18
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 2022-10-10
D · Potential for more than minimal harm
2022-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-10
E · Potential for more than minimal harm
2019-09-06
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 2019-10-20
D · Potential for more than minimal harm
2019-09-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-10-20
D · Potential for more than minimal harm
2019-09-06
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 2019-10-20
D · Potential for more than minimal harm
2019-09-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-20
D · Potential for more than minimal harm
2019-09-06
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 2019-10-20
C · Minimal harm
2019-09-06
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-10-20
Penalties and ownership
What sits behind the stars
Ownership
Bhavnani, Jayshree
Operational/Managerial Control · Individual
Bhavnani, Jayshree
Corporate Officer · Individual
Matney, Jimmy
Operational/Managerial Control · Individual
Matney, Jimmy
Corporate Officer · Individual
Sloan, Jo
Operational/Managerial Control · Individual
Swartzentruber, Gary
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Pruitthealth - Moultrie
Moultrie, GA
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
#2
Pruitthealth - Magnolia Manor
Moultrie, GA
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Sunrise
Moultrie, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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