Cycle 1
Health 2025-07-02 · Fire 2025-07-02
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Thomaston, GA
Harborview Health Systems Thomaston
3-star overall rating with 3-star inspections with 3 recent health deficiencies
310 Avenue F, Thomaston, GA
(706) 647-6676
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
119
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-11-01
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
0.31
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.64
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.36
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.14
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
0.28
CMS adjusted RN staffing hours
Adjusted total hours
2.71
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,797
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9866
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.89% · Performance 21.88% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.35
Baseline 6.62% · Performance 6.24% · Measure score 5.35 · Achievement 5.35 · Improvement 1.87
Total nurse turnover
7.31
Baseline 51.25% · Performance 33.78% · Measure score 7.31 · Achievement 7.31 · Improvement 6.12
Adjusted total nurse staffing
0
Baseline 2.70 hours · Performance 2.55 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 7.14% · Lower 95% interval 6.72% |
| Discharge to community | 48.35% |
50.57%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 40% · Lower 95% interval 36.77% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.04% |
95.27%
2.8 pts better
|
Numerator 50 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 39.39% |
53.69%
14.3 pts worse
|
Numerator 13 · Denominator 33 |
| Discharge mobility score | 30.3% |
50.94%
20.6 pts worse
|
Numerator 10 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 3.92% |
2.29%
1.6 pts worse
|
Numerator 2 · Denominator 51 · Adjusted rate 2.7% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 2.33% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | 16.06% |
42%
25.9 pts worse
|
Numerator 22 · Denominator 137 |
| Discharge function score | 39.39% |
56.45%
17.1 pts worse
|
Numerator 13 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.08% |
25.2%
2.1 pts worse
|
Numerator 6 · Denominator 26 |
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 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.2%
8.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.0%
4.1 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.2%
1.1 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.0% · Q3 1.1% · Q4 2.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 35.7% |
9.6%
26.1 pts worse
|
11.4%
24.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.9% · Q2 34.4% · Q3 34.1% · Q4 32.9% · 4Q avg 35.7% |
| Percentage of long-stay residents who lose too much weight | 19.7% |
5.9%
13.8 pts worse
|
5.4%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 24.1% · Q3 23.7% · Q4 9.1% · 4Q avg 19.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.2% |
20.7%
2.5 pts worse
|
19.6%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 25.0% · Q3 25.3% · Q4 17.9% · 4Q avg 23.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.0% |
21.4%
4.6 pts worse
|
16.7%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 29.8% · Q3 21.1% · Q4 22.8% · 4Q avg 26.0% · 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 | 19.6% |
17.9%
1.7 pts worse
|
16.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 12.7% · Q3 23.3% · Q4 28.0% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.4% |
16.2%
2.8 pts better
|
14.9%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 14.1% · Q3 9.5% · Q4 13.5% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.1%
0.7 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.1% |
2.5%
3.6 pts worse
|
1.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.0% · Q3 4.5% · Q4 6.7% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.0% |
16.1%
7.1 pts better
|
19.8%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 12.0% · Q3 8.7% · Q4 6.6% · 4Q avg 9.0% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
6.2%
1.9 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 6.7% · Q3 8.4% · Q4 8.7% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
80.4%
14.2 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 88.5% · Q3 95.7% · Q4 96.2% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.1% |
12.2%
7.1 pts better
|
12.0%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.1% · Observed 5.3% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
2.2%
1.2 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.5% · Q4 3.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
78.2%
20.2 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
24.2%
4 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 21.1% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-01 · Fire 2023-09-01
12 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-07-22 · Fire 2022-07-22
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-09-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-16
F · Potential for more than minimal harm
2023-09-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
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 2023-10-16
F · Potential for more than minimal harm
2022-07-22
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-09-05
F · Potential for more than minimal harm
2022-07-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-05
E · Potential for more than minimal harm
2022-07-22
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-07-22
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 2022-09-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-16
E · Potential for more than minimal harm
2025-07-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-16
E · Potential for more than minimal harm
2024-10-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-03
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-11-17
E · Potential for more than minimal harm
2023-09-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-16
F · Potential for more than minimal harm
2022-07-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-05
E · Potential for more than minimal harm
2022-07-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-07-22
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-07-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-07-22
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-07-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-07-22
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 2022-09-05
D · Potential for more than minimal harm
2022-07-22
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 2022-09-05
D · Potential for more than minimal harm
2022-07-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-07-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-07-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-09-05
D · Potential for more than minimal harm
2022-07-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-09-05
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
Englander, David
Corporate Officer · Individual
Lee, Nelva
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Riverside Health And Rehabilitation
Thomaston, GA
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Providence Healthcare
Thomaston, GA
2-star overall rating with 3-star inspections with 5 recent health deficiencies
#3
Heritage Inn Of Barnesville Health And Rehab
Barnesville, GA
3-star overall rating with 4-star inspections with 2 recent health deficiencies
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