Cycle 1
Health 2025-02-14 · Fire 2025-02-14
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cuthbert, GA
Joe-Anne Burgin Health And Rehabilitation
4-star overall rating with 4-star inspections with $16,706 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
321 Randolph Street, Cuthbert, GA
(229) 732-2288
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1979-12-01
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
0.60
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.49
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
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
531
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.13
Composite VBP score used to determine payment impact.
Payment multiplier
1.0214
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 28.95% · Performance 16.95% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.63
Baseline 3.73 hours · Performance 4.11 hours · Measure score 3.63 · Achievement 3.63 · Improvement 1.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.14% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 30% · Lower 95% interval 9.04% |
| Discharge to community | 38.26% |
50.57%
12.3 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 21.95% · Lower 95% interval 23.8% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 85.71% |
95.27%
9.6 pts worse
|
Numerator 30 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | 38.1% |
53.69%
15.6 pts worse
|
Numerator 8 · Denominator 21 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 7 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 11.43% |
2.29%
9.1 pts worse
|
Numerator 4 · Denominator 35 · Adjusted rate 7.87% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 113 |
| Staff flu vaccination coverage | 76.04% |
42%
34 pts better
|
Numerator 73 · Denominator 96 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 11 · Denominator 21 |
| 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 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 98.3% |
91.2%
7.1 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 98.5% · Q3 100.0% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
95.0%
3.7 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| 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 1.4% · Q2 1.5% · Q3 2.8% · Q4 2.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
9.6%
9.2 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 9.0% |
5.9%
3.1 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.3% · Q3 12.1% · Q4 10.4% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
20.7%
6.9 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 15.6% · Q3 13.4% · Q4 14.9% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
21.4%
0.3 pts worse
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 19.0% · Q3 21.6% · Q4 21.2% · 4Q avg 21.7% · 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 | 12.1% |
17.9%
5.8 pts better
|
16.3%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 8.5% · Q3 7.4% · Q4 14.7% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
16.2%
0.5 pts worse
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 12.9% · Q3 23.8% · Q4 16.9% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.1%
0.1 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 2.1% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.5%
1.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 0.0% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.6% |
16.1%
3.5 pts better
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.5% · Q3 14.6% · Q4 5.6% · 4Q avg 12.6% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
6.2%
2.5 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.4% · Q3 10.6% · Q4 11.9% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
80.4%
15.2 pts better
|
81.7%
13.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.9% · Q2 97.5% · Q3 97.0% · Q4 100.0% · 4Q avg 95.6% |
| 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 · 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 | 92.9% |
78.2%
14.7 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-27 · Fire 2023-04-27
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-10-21 · Fire 2021-10-21
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
D · Potential for more than minimal harm
2025-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-20
D · Potential for more than minimal harm
2023-04-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-11-04
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 2024-10-29
G · Actual harm
2023-04-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-04-27
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 2023-05-22
D · Potential for more than minimal harm
2023-04-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-27
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-05-22
E · Potential for more than minimal harm
2021-10-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-12-05
D · Potential for more than minimal harm
2021-10-21
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 2021-12-05
Penalties and ownership
What sits behind the stars
$5,077
2024-11-04
Fine
Fine · fine $5,077
Fine
$3,728
2023-04-27
Fine
Fine · fine $3,728
Fine
$7,901
2023-04-27
Fine
Fine · fine $7,901
Fine
Ownership
Health Scholarships Inc
5% Or Greater Direct Ownership Interest · Organization
Brookings, Stephanie
W-2 Managing Employee · Individual
Clinical Services Inc
Operational/Managerial Control · Organization
Lewis, Adrian
Corporate Officer · Individual
Lewis, Adrian
W-2 Managing Employee · Individual
Satchell, Michael
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Calhoun Nursing Home
Edison, GA
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Fort Gaines Health And Rehab
Fort Gaines, GA
2-star overall rating with 2-star inspections with 12 recent health deficiencies
#3
Dawson Health And Rehabilitation
Dawson, GA
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $121,401 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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