Cycle 1
Health 2024-12-19 · Fire 2024-12-19
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Springfield, GA
Effingham Care & Rehabilitation Center
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
459 Highway 119 South, Springfield, GA
(912) 754-6451
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1969-08-25
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.38
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
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,679
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
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
4.24
Baseline 39.13% · Performance 46.34% · Measure score 4.24 · Achievement 4.24 · Improvement 0
Adjusted total nurse staffing
1.57
Baseline 4.66 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.99% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 5.94% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · 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 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.8% |
8.2%
4.4 pts worse
|
Numerator 6 · Denominator 158 |
| Staff flu vaccination coverage | 74.07% |
42%
32.1 pts better
|
Numerator 120 · Denominator 162 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · 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 | 1.1 |
2.2
1.1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.2 · 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 96.7% · Q2 93.4% · Q3 98.8% · Q4 98.8% · 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 | 2.5% |
3.2%
0.7 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.2% · Q3 2.4% · Q4 3.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
9.6%
7.1 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.7% · Q3 2.6% · Q4 1.4% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.9%
1.9 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 12.3% · Q3 2.5% · Q4 7.7% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
20.7%
2.2 pts better
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 19.3% · Q3 18.5% · Q4 19.0% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.0% |
21.4%
3.4 pts better
|
16.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 19.4% · Q3 17.7% · Q4 17.9% · 4Q avg 18.0% · 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 | 18.2% |
17.9%
0.3 pts worse
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 11.2% · Q4 6.2% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.2% |
16.2%
1 pts worse
|
14.9%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 26.1% · Q3 11.3% · Q4 12.9% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.1%
0.4 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 3.4% · Q4 1.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.5%
0.3 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.4% · Q3 4.7% · Q4 1.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.8% |
16.1%
1.3 pts better
|
19.8%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 28.8% · Q3 11.1% · Q4 13.6% · 4Q avg 14.8% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
6.2%
2.3 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.6% · Q3 5.6% · Q4 1.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.3% |
80.4%
10.1 pts worse
|
81.7%
11.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 83.3% · Q4 90.9% · 4Q avg 70.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 14.3% |
2.2%
12.1 pts worse
|
1.6%
12.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
78.2%
11.8 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-25 · Fire 2022-09-25
1 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-02-27 · Fire 2020-02-27
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
F · Potential for more than minimal harm
2024-12-19
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-09-25
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-11-09
Penalties and ownership
What sits behind the stars
Ownership
Effingham Hospital Inc
5% Or Greater Direct Ownership Interest · Organization
Allen, Alia
W-2 Managing Employee · Individual
Baker-Witt, Fran
Operational/Managerial Control · Individual
Baker-Witt, Fran
Corporate Director · Individual
Baker-Witt, Fran
Corporate Officer · Individual
Baker-Witt, Fran
W-2 Managing Employee · Individual
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