Cycle 1
Health 2025-04-10 · Fire 2025-04-10
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Jesup, GA
Harborview Health Systems Jesup
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
1090 W Orange St, Jesup, GA
(912) 427-6858
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-08-01
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
0.77
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.94
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,287
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.19% · Performance 22.36% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.23
Baseline 10.58% · Performance 9.06% · Measure score 2.23 · Achievement 0 · Improvement 2.23
Total nurse turnover
8.67
Baseline 45.24% · Performance 28.23% · Measure score 8.67 · Achievement 8.67 · Improvement 7.84
Adjusted total nurse staffing
0
Baseline 3.26 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.87% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 129 · Observed rate 10.08% · Lower 95% interval 7.38% |
| Discharge to community | 49.42% |
50.57%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 42.67% · Lower 95% interval 40.76% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.37% |
95.27%
4.1 pts better
|
Numerator 158 · Denominator 159 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 159 |
| Discharge self-care score | 53.01% |
53.69%
0.7 pts worse
|
Numerator 44 · Denominator 83 |
| Discharge mobility score | 48.19% |
50.94%
2.8 pts worse
|
Numerator 40 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 1.26% |
2.29%
1 pts better
|
Numerator 2 · Denominator 159 · Adjusted rate 1.26% |
| Healthcare-associated infections requiring hospitalization | 9.06% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 10.75% · Lower 95% interval 5.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 150 |
| Staff flu vaccination coverage | 29.41% |
42%
12.6 pts worse
|
Numerator 50 · Denominator 170 |
| Discharge function score | 61.45% |
56.45%
5 pts better
|
Numerator 51 · Denominator 83 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 98 · Denominator 98 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.3% |
25.2%
15.9 pts worse
|
Numerator 8 · Denominator 86 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.0 |
2.2
1.8 pts worse
|
1.9
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 4.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.0
1.5 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.4 · Expected 1.6 · 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 | 2.3% |
3.2%
0.9 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.9% · Q3 2.7% · Q4 1.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 39.6% |
9.6%
30 pts worse
|
11.4%
28.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 38.2% · Q3 47.8% · Q4 31.9% · 4Q avg 39.6% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.9%
1.9 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.0% · Q3 3.1% · Q4 3.1% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
20.7%
10.5 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 11.9% · Q3 10.4% · Q4 4.5% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.5% |
21.4%
10.1 pts worse
|
16.7%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 32.1% · Q3 30.4% · Q4 31.6% · 4Q avg 31.5% · 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 | 21.2% |
17.9%
3.3 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 11.3% · Q3 12.4% · Q4 41.7% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
16.2%
0.1 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 19.7% · Q3 16.7% · Q4 15.4% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.1%
0.2 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 2.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.5%
0.7 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.9% · Q3 1.4% · Q4 4.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.9% |
16.1%
2.8 pts worse
|
19.8%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 23.3% · Q3 12.7% · Q4 20.8% · 4Q avg 18.9% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
6.2%
3.2 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.8% · Q3 4.5% · Q4 1.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
80.4%
19.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
12.2%
2 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 15.0% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.2%
1.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
78.2%
20.7 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.0% |
24.2%
8.8 pts worse
|
23.9%
9.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.0% · Observed 33.3% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-27 · Fire 2023-04-27
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-05-27 · Fire 2021-05-27
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-05
D · Potential for more than minimal harm
2023-04-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-19
F · Potential for more than minimal harm
2021-05-27
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-06-21
F · Potential for more than minimal harm
2021-05-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-06-21
F · Potential for more than minimal harm
2021-05-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-06-21
F · Potential for more than minimal harm
2021-05-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-06-21
D · Potential for more than minimal harm
2021-05-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-21
D · Potential for more than minimal harm
2021-05-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-06-21
D · Potential for more than minimal harm
2021-05-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-21
D · Potential for more than minimal harm
2021-05-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-06-21
D · Potential for more than minimal harm
2021-05-27
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2021-06-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-04-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-19
F · Potential for more than minimal harm
2021-05-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-21
E · Potential for more than minimal harm
2021-05-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-06-21
D · Potential for more than minimal harm
2021-05-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-06-21
D · Potential for more than minimal harm
2021-05-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-06-21
Penalties and ownership
What sits behind the stars
Ownership
Harborview Health Systems Inc
5% Or Greater Direct Ownership Interest · Organization
Englander, David
5% Or Greater Indirect Ownership Interest · Individual
Leibowitz, Chaim
5% Or Greater Indirect Ownership Interest · Individual
Denison, Angela
W-2 Managing Employee · Individual
Englander, David
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Altamaha Healthcare Center
Jesup, GA
1-star overall rating with 1-star inspections with $4,017 in total fines with 13 recent health deficiencies
#2
Jesup Health And Rehab
Jesup, GA
1-star overall rating with 1-star inspections with $45,968 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Coastal Manor
Ludowici, GA
1-star overall rating with 2-star inspections with 2 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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