Cycle 1
Health 2025-03-27 · Fire 2025-03-27
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bishop, GA
High Shoals Health And Rehabilitation
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
3450 New High Shoals Rd, Bishop, GA
(706) 769-7738
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
86
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1981-04-06
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
0.48
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.04
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.89
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
30%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,388
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.50
Baseline 19.86% · Performance 21.20% · Measure score 0.50 · Achievement 0.50 · Improvement 0
Healthcare-associated infections
0
Baseline 6.42% · Performance 8.04% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.59
Baseline 44.83% · Performance 40.84% · Measure score 5.59 · Achievement 5.59 · Improvement 1.49
Adjusted total nurse staffing
0.68
Baseline 3.32 hours · Performance 3.27 hours · Measure score 0.68 · Achievement 0.68 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.44% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 10.39% · Lower 95% interval 7.52% |
| Discharge to community | 57.41% |
50.57%
6.8 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 51.43% · Lower 95% interval 44.66% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.78% |
95.27%
2.5 pts better
|
Numerator 44 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 19.44% |
53.69%
34.2 pts worse
|
Numerator 7 · Denominator 36 |
| Discharge mobility score | 27.78% |
50.94%
23.2 pts worse
|
Numerator 10 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 45 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.04% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 10.2% · Lower 95% interval 4.61% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 62.07% |
42%
20.1 pts better
|
Numerator 72 · Denominator 116 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 12 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
91.2%
7.8 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| 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 | 4.6% |
3.2%
1.4 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.9% · Q3 4.0% · Q4 6.3% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
9.6%
6.8 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.1% · Q3 1.4% · Q4 2.7% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
5.9%
0.4 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.8% · Q3 6.0% · Q4 7.8% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.6% |
20.7%
9.1 pts better
|
19.6%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 11.6% · Q3 13.4% · Q4 10.9% · 4Q avg 11.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.0% |
21.4%
7.6 pts worse
|
16.7%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 24.6% · Q3 32.8% · Q4 33.3% · 4Q avg 29.0% · 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 | 14.3% |
17.9%
3.6 pts better
|
16.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 6.9% · Q3 18.3% · Q4 9.8% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
16.2%
5.7 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 10.4% · Q3 12.3% · Q4 11.5% · 4Q avg 10.5% · 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 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.5%
1.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.3% |
16.1%
5.8 pts better
|
19.8%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 6.5% · Q3 12.7% · Q4 12.3% · 4Q avg 10.3% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.2%
0.4 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 3.2% · Q3 7.2% · Q4 5.6% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
80.4%
15.5 pts better
|
81.7%
14.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.9% · Q3 95.2% · Q4 93.8% · 4Q avg 95.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.4% |
12.2%
7.8 pts better
|
12.0%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 3.7% · Expected 9.5% · 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 | 90.2% |
78.2%
12 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.6% |
24.2%
10.6 pts better
|
23.9%
10.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 11.1% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-13 · Fire 2022-11-13
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-11
E · Potential for more than minimal harm
2025-03-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-11
D · Potential for more than minimal harm
2025-03-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-11
D · Potential for more than minimal harm
2025-03-27
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 2025-05-11
D · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-11
D · Potential for more than minimal harm
2025-03-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-11
D · Potential for more than minimal harm
2025-03-27
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-05-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-11
D · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-11
F · Potential for more than minimal harm
2023-11-16
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 2023-12-31
F · Potential for more than minimal harm
2023-11-16
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-12-31
E · Potential for more than minimal harm
2023-11-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-12-31
E · Potential for more than minimal harm
2023-11-16
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-12-31
D · Potential for more than minimal harm
2023-11-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-31
D · Potential for more than minimal harm
2023-11-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-31
D · Potential for more than minimal harm
2022-11-13
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-11-13
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 2022-12-28
Penalties and ownership
What sits behind the stars
Ownership
Community Health Systems Inc
5% Or Greater Indirect Ownership Interest · Organization
Health Scholarships Inc
5% Or Greater Direct Ownership Interest · Organization
Clinical Services Inc
Operational/Managerial Control · Organization
Harrison, Brandi
Operational/Managerial Control · Individual
Lambert, Reno
Operational/Managerial Control · Individual
Peters, Laura
Operational/Managerial Control · Individual
Ringer, Dave
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
University Nursing & Rehab Ctr
Athens, GA
2-star overall rating with 3-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Presbyterian Village - Athens
Athens, GA
2-star overall rating with 2-star inspections with $18,545 in total fines with 1 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Athens Heritage
Athens, GA
2-star overall rating with 3-star inspections with $16,801 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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