Cycle 1
Health 2019-12-05 · Fire 2019-12-05
1 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Georgiana, AL
Georgiana Health And Rehabilitation, LLC
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
206 Palmer Avenue, Georgiana, AL
(334) 376-2267
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
91
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1977-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 3 overall / 3 health / 4 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
0.44
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.95
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,062
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9862
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.93% · Performance 21.35% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.79% · Performance 7.97% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.64
Performance 32.47% · Measure score 7.64 · Achievement 7.64 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.71
Baseline 4.71 hours · Performance 4.42 hours · Measure score 4.71 · Achievement 4.71 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.92% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 5.17% · Lower 95% interval 6.48% |
| Discharge to community | 47.83% |
50.57%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 39.58% · Lower 95% interval 36.71% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 25 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 1 · Denominator 26 · Adjusted rate 4.27% |
| Healthcare-associated infections requiring hospitalization | 7.97% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 10% · Lower 95% interval 4.27% |
| Staff COVID-19 vaccination coverage | 17.43% |
8.2%
9.2 pts better
|
Numerator 19 · Denominator 109 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · 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 | 1.5 |
2.0
0.5 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.0 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.3%
8.4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.7% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.2% |
94.8%
0.6 pts worse
|
95.5%
1.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.4%
1.8 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.6% · Q4 2.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.3%
1.3 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 | 17.8% |
5.3%
12.5 pts worse
|
5.4%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.3% · Q2 20.0% · Q3 3.2% · Q4 6.2% · 4Q avg 17.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
24.9%
0.1 pts better
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 23.9% · Q3 25.0% · Q4 23.4% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.9% |
22.8%
9.1 pts worse
|
16.7%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 31.9% · Q3 27.9% · Q4 31.8% · 4Q avg 31.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.6%
0.6 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 | 10.4% |
14.8%
4.4 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 25.1% · Q3 0.0% · Q4 8.7% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
13.4%
0.1 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 24.6% · Q3 9.4% · Q4 5.4% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.3%
0.8 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.6%
0.9 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.6% · Q3 5.2% · Q4 3.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.9% |
13.5%
3.4 pts worse
|
19.8%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 25.2% · Q3 8.6% · Q4 11.2% · 4Q avg 16.9% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.7%
0.6 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.3% · Q3 3.7% · Q4 1.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
84.3%
13.1 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.1% · Q4 92.9% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.5% |
11.5%
10 pts worse
|
12.0%
9.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 27.3% · Expected 14.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.6% |
2.1%
5.5 pts worse
|
1.6%
6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
80.3%
13.5 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.7% |
24.5%
9.2 pts worse
|
23.9%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.7% · Observed 36.4% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2018-12-13 · Fire 2018-12-13
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-02-22 · Fire 2018-02-22
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2019-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-12-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-12-23
E · Potential for more than minimal harm
2018-12-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-12-26
D · Potential for more than minimal harm
2018-12-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-16
F · Potential for more than minimal harm
2018-02-22
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-04-02
E · Potential for more than minimal harm
2018-02-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-04-02
D · Potential for more than minimal harm
2018-02-22
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2018-04-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2019-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-21
D · Potential for more than minimal harm
2018-12-13
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 2019-01-09
D · Potential for more than minimal harm
2018-12-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-01-09
D · Potential for more than minimal harm
2018-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-03
D · Potential for more than minimal harm
2018-02-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2018-03-12
Penalties and ownership
What sits behind the stars
Ownership
Nhs Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Estes, James
Corporate Officer · Individual
Georgiana Health Realty, LLC
5% Or Greater Security Interest · Organization
Hartley, Matilda
Operational/Managerial Control · Individual
Hartley, Matilda
W-2 Managing Employee · Individual
Long, Phillip
Corporate Officer · Individual
Macdonald-Lamier, Starann
Operational/Managerial Control · Individual
Macdonald-Lamier, Starann
Corporate Director · Individual
Nhs Facilities Group LLC
5% Or Greater Security Interest · Organization
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Servisfirst Bank
5% Or Greater Security Interest · Organization
Simmons, Alice
Operational/Managerial Control · Individual
Simmons, Alice
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Crowne Health Care Of Greenville
Greenville, AL
4-star overall rating with 4-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Evergreen Nursing Home
Evergreen, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Luverne Health And Rehabilitation, LLC
Luverne, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
Jump out