Gracewood, GA

Gracewood Nsg Facility(Unit 9)

5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle

100 Myrtle Blvd., East Central Reg Hosp, Gracewood, GA

(706) 790-2012

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

0 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

56

Certified beds

Average residents

16

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1977-10-01

CMS approved date

Coverage

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

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission Not Available
10.72%
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community Not Available
50.57%
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary Not Available
1.02
This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up Not Available
95.27%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury Not Available
0.77%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score Not Available
53.69%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score Not Available
50.94%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened Not Available
2.29%
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization Not Available
7.12%
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage Not Available
8.2%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage Not Available
42%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score Not Available
56.45%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
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 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury 0.0%
3.2%
3.2 pts better
3.3%
3.3 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.0%
9.6%
9.6 pts better
11.4%
11.4 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight 0.0%
5.9%
5.9 pts better
5.4%
5.4 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 25.8%
20.7%
5.1 pts worse
19.6%
6.2 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.8%
Percentage of long-stay residents who received an antipsychotic medication 17.4%
21.4%
4 pts better
16.7%
0.7 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.4% · 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 · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased 4.3%
16.2%
11.9 pts better
14.9%
10.6 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.3% · 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 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 9.5%
2.5%
7 pts worse
1.7%
7.8 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 1.8%
16.1%
14.3 pts better
19.8%
18 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8%
Percentage of long-stay residents with pressure ulcers 1.3%
6.2%
4.9 pts better
5.1%
3.8 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-20 · Fire 2025-03-20

0 health deficiencies

No concentrated health issue counts in this cycle.

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2023-10-26 · Fire 2023-10-26

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-05-04 · Fire 2022-05-04

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

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 2025-03-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-03

Inspection history

Recent health citations

D · Potential for more than minimal harm 2022-05-04

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-08-29

Penalties and ownership

What sits behind the stars

Ownership

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Fines
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