Cycle 1
Health 2025-04-13 · Fire 2025-04-13
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Calhoun, GA
Gordon Health And Rehabilitation
5-star overall rating with 5-star inspections with 2 recent health deficiencies
1280 Mauldin Road Ne, Calhoun, GA
(706) 625-0044
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
113
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1995-07-01
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
0.21
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.87
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.22
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,513
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.35
Composite VBP score used to determine payment impact.
Payment multiplier
1.0033
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.82
Baseline 18.20% · Performance 19.20% · Measure score 4.82 · Achievement 4.82 · Improvement 0
Healthcare-associated infections
7.11
Baseline 6.22% · Performance 5.71% · Measure score 7.11 · Achievement 7.11 · Improvement 3.67
Total nurse turnover
7.23
Baseline 37.21% · Performance 34.12% · Measure score 7.23 · Achievement 7.23 · Improvement 2
Adjusted total nurse staffing
0.58
Baseline 3.1 hours · Performance 3.24 hours · Measure score 0.58 · Achievement 0.58 · Improvement 0.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.47% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 137 · Observed rate 5.11% · Lower 95% interval 5.68% |
| Discharge to community | 59.63% |
50.57%
9.1 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 53.98% · Lower 95% interval 49.52% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 63.92% |
95.27%
31.3 pts worse
|
Numerator 62 · Denominator 97 |
| Falls with major injury | 4.12% |
0.77%
3.4 pts worse
|
Numerator 4 · Denominator 97 |
| Discharge self-care score | 36.71% |
53.69%
17 pts worse
|
Numerator 29 · Denominator 79 |
| Discharge mobility score | 22.78% |
50.94%
28.2 pts worse
|
Numerator 18 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 11.34% |
2.29%
9.1 pts worse
|
Numerator 11 · Denominator 97 · Adjusted rate 9.89% |
| Healthcare-associated infections requiring hospitalization | 5.71% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 2.5% · Lower 95% interval 3.24% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 140 |
| Staff flu vaccination coverage | 72.41% |
42%
30.4 pts better
|
Numerator 126 · Denominator 174 |
| Discharge function score | 39.24% |
56.45%
17.2 pts worse
|
Numerator 31 · Denominator 79 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 46 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 47.62% |
25.2%
22.4 pts better
|
Numerator 20 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.0 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.2%
8.1 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.1% · Q3 99.0% · Q4 99.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
95.0%
3.3 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.2%
1.7 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 1.0% · Q4 1.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
9.6%
9.3 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.9%
1.4 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.5% · Q3 6.5% · Q4 3.4% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
20.7%
0.1 pts worse
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 21.5% · Q3 21.5% · Q4 18.0% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
21.4%
6.1 pts better
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 18.5% · Q3 14.1% · Q4 14.7% · 4Q avg 15.3% · 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 | 16.8% |
17.9%
1.1 pts better
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 16.3% · Q3 24.0% · Q4 7.1% · 4Q avg 16.8% · 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 10.7% · Q2 13.8% · Q3 19.3% · Q4 12.8% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.2% |
2.5%
6.7 pts worse
|
1.7%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.8% · Q3 8.7% · Q4 11.1% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
16.1%
5.2 pts worse
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 27.4% · Q3 19.6% · Q4 21.3% · 4Q avg 21.3% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
6.2%
2.1 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 12.3% · Q3 7.6% · Q4 5.8% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
80.4%
14.6 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 98.8% · Q3 94.3% · Q4 94.1% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
12.2%
4.1 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 16.2% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.2%
21.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
24.2%
0.4 pts worse
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 25.0% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-02 · Fire 2023-03-02
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2021-09-24 · Fire 2021-09-24
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
D · Potential for more than minimal harm
2023-03-02
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-04-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-28
C · Minimal harm
2023-03-02
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 2023-04-04
Penalties and ownership
What sits behind the stars
Ownership
Blake, Wyatt
Operational/Managerial Control · Individual
Clinical Services Inc
Operational/Managerial Control · Organization
Lambert, Reno
Operational/Managerial Control · Individual
Washington, Frederick
Operational/Managerial Control · Individual
Wilson, Tammy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Calhoun Crossing Of Journey LLC
Calhoun, GA
1-star overall rating with 1-star inspections with $107,867 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Ridgewood Manor Health And Rehabilitation
Dalton, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Regency Park Health And Rehabilitation
Dalton, GA
5-star overall rating with 4-star inspections with $8,512 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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