Cycle 1
Health 2025-05-30 · Fire 2025-05-30
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Jesup, GA
Jesup Health And Rehab
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
3100 Savannah Highway, Jesup, GA
(912) 427-6873
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Health Communities
Operator or chain grouping
Approved since
1990-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
40 facilities
Chain averages 3 overall / 3 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
0.25
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.86
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
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,931
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.24% · Performance 22.03% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.76
Baseline 4.94% · Performance 7.01% · Measure score 2.76 · Achievement 2.76 · Improvement 0
Total nurse turnover
5.69
Baseline 61.36% · Performance 40.43% · Measure score 5.69 · Achievement 5.69 · Improvement 5.23
Adjusted total nurse staffing
0.35
Baseline 2.51 hours · Performance 2.79 hours · Measure score 0.35 · Achievement 0 · Improvement 0.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.82% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 12.16% · Lower 95% interval 7.41% |
| Discharge to community | 47.67% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 38.78% · Lower 95% interval 37.34% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 92.86% |
95.27%
2.4 pts worse
|
Numerator 65 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 16 · Denominator 40 |
| Discharge mobility score | 42.5% |
50.94%
8.4 pts worse
|
Numerator 17 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 8.57% |
2.29%
6.3 pts worse
|
Numerator 6 · Denominator 70 · Adjusted rate 6.38% |
| Healthcare-associated infections requiring hospitalization | 7.01% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 1.49% |
8.2%
6.7 pts worse
|
Numerator 1 · Denominator 67 |
| Staff flu vaccination coverage | 40.87% |
42%
1.1 pts worse
|
Numerator 47 · Denominator 115 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 20 · Denominator 40 |
| Transfer of health information to provider | 97.62% |
95.95%
1.7 pts better
|
Numerator 41 · Denominator 42 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 12 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.2
0.3 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.0
1.2 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
91.2%
6.8 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 100.0% · Q3 98.0% · Q4 100.0% · 4Q avg 98.0% |
| 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 | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 2.0% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.7% |
9.6%
17.1 pts worse
|
11.4%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 23.3% · Q3 26.2% · Q4 25.6% · 4Q avg 26.7% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
5.9%
3.7 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.5% · Q3 15.4% · Q4 10.5% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
20.7%
0.7 pts better
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 23.3% · Q3 19.5% · Q4 15.4% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.8% |
21.4%
7.4 pts worse
|
16.7%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 24.2% · Q3 29.4% · Q4 30.3% · 4Q avg 28.8% · 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 | 23.3% |
17.9%
5.4 pts worse
|
16.3%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.8% |
16.2%
1.6 pts worse
|
14.9%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.9% · Q3 21.6% · Q4 14.7% · 4Q avg 17.8% · 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 1.6% · Q2 0.0% · 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 | 4.7% |
2.5%
2.2 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 8.5% · Q4 4.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
16.1%
3.4 pts worse
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 23.2% · Q3 19.6% · Q4 10.9% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
6.2%
2.4 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.7% · Q3 6.4% · Q4 10.7% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
80.4%
6.1 pts better
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 83.0% · Q3 81.1% · Q4 90.3% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
12.2%
3.8 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 17.9% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
2.2%
3.4 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 3.0% · Q4 2.4% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.8% |
78.2%
9.6 pts better
|
79.7%
8.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
24.2%
7.2 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 35.7% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-22 · Fire 2023-06-22
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-10-14 · Fire 2021-10-14
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
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
2025-05-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Not marked corrected
D · Potential for more than minimal harm
2025-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
D · Potential for more than minimal harm
2025-05-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Not marked corrected
F · Potential for more than minimal harm
2023-06-22
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-06-22
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-06-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-06-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-22
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-30
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-05-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-08
K · Immediate jeopardy
2024-11-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-16
K · Immediate jeopardy
2024-11-18
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 2024-12-16
K · Immediate jeopardy
2024-11-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-16
K · Immediate jeopardy
2024-11-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-12-16
D · Potential for more than minimal harm
2023-06-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-22
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-31
F · Potential for more than minimal harm
2021-10-14
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 2021-11-28
E · Potential for more than minimal harm
2021-10-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-11-28
E · Potential for more than minimal harm
2021-10-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-11-28
E · Potential for more than minimal harm
2021-10-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-11-28
D · Potential for more than minimal harm
2021-10-14
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 2021-11-28
D · Potential for more than minimal harm
2021-10-14
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 2021-11-28
D · Potential for more than minimal harm
2021-10-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-11-28
D · Potential for more than minimal harm
2021-10-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-28
Penalties and ownership
What sits behind the stars
$45,968
2024-11-18
Fine
Fine · fine $45,968
Fine
Ownership
Gbd LLC
5% Or Greater Direct Ownership Interest · Organization
Barnes, Michelle
Operational/Managerial Control · Individual
Barres, LLC
5% Or Greater Indirect Ownership Interest · Organization
Crino, Bryan
5% Or Greater Indirect Ownership Interest · Individual
Delker, Michelle
Corporate Officer · Individual
Feuer, Scott
5% Or Greater Indirect Ownership Interest · Individual
Lindeman, Stuart
5% Or Greater Indirect Ownership Interest · Individual
Lindeman, Stuart
Corporate Officer · Individual
Mane, Meagan
Operational/Managerial Control · Individual
Mission Health Of Georgia, LLC
Operational/Managerial Control · Organization
Passero, Joseph
5% Or Greater Indirect Ownership Interest · Individual
T And C Capital Assets, LLC
5% Or Greater Indirect Ownership Interest · Organization
Windward Health Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
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
Harborview Health Systems Jesup
Jesup, GA
5-star overall rating with 5-star inspections with 2 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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