Lagrange, GA

Lagrange Care Center LLC

3-star overall rating with 3-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

2111 West Point Road, Lagrange, GA

(706) 812-9293

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

138

Certified beds

Average residents

108

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Peach Health Group

Operator or chain grouping

Approved since

1989-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

10 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

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

0.38

Registered nurse staffing · state 0.49 · national 0.68

LPN hours / resident day

0.81

Licensed practical nurse staffing · state 0.93 · national 0.87

Aide hours / resident day

2.83

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

4.02

All reported nurse hours · state 3.57 · national 3.89

Licensed hours

1.20

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

3.40

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.25

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

0.38

CMS adjusted RN staffing hours

Adjusted total hours

3.98

CMS adjusted total nurse staffing hours

Case-mix index

1.38

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,703

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.77

Composite VBP score used to determine payment impact.

Payment multiplier

0.9830

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.18

Baseline 22.17% · Performance 20.28% · Measure score 3.18 · Achievement 2.49 · Improvement 3.18

Healthcare-associated infections

3.43

Baseline 8.09% · Performance 6.87% · Measure score 3.43 · Achievement 3.22 · Improvement 3.43

Total nurse turnover

2.50

Baseline 63.38% · Performance 53.45% · Measure score 2.50 · Achievement 2.50 · Improvement 2.08

Adjusted total nurse staffing

Baseline 3.04 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.13%	10.72% 0.4 pts worse	No Different than the National Rate · Eligible stays 64 · Observed rate 12.5% · Lower 95% interval 7.33%
Discharge to community	39.98%	50.57% 10.6 pts worse	No Different than the National Rate · Eligible stays 45 · Observed rate 26.67% · Lower 95% interval 26.25%
Medicare spending per beneficiary	1.21	1.02 0.2 pts worse
Drug regimen review with follow-up	93.94%	95.27% 1.3 pts worse	Numerator 62 · Denominator 66
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 66
Discharge self-care score	63.16%	53.69% 9.5 pts better	Numerator 24 · Denominator 38
Discharge mobility score	57.89%	50.94% 7 pts better	Numerator 22 · Denominator 38
Pressure ulcers or injuries, new or worsened	3.03%	2.29% 0.7 pts worse	Numerator 2 · Denominator 66 · Adjusted rate 2.22%
Healthcare-associated infections requiring hospitalization	6.87%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 3.94%
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Staff flu vaccination coverage	22.96%	42% 19 pts worse	Numerator 45 · Denominator 196
Discharge function score	65.79%	56.45% 9.3 pts better	Numerator 25 · Denominator 38
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 23 · Denominator 23
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	4%	25.2% 21.2 pts worse	Numerator 2 · Denominator 50

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.0	2.2 0.2 pts better	1.9 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	5.0	2.0 3 pts worse	1.8 3.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 5.0 · Observed 5.0 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	50.7%	91.2% 40.5 pts worse	93.4% 42.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 79.3% · Q2 60.0% · Q3 41.4% · Q4 26.0% · 4Q avg 50.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	59.2%	95.0% 35.8 pts worse	95.5% 36.3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 59.2%
Percentage of long-stay residents experiencing one or more falls with major injury	2.6%	3.2% 0.6 pts better	3.3% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.2% · Q3 2.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.0%	9.6% 3.6 pts better	11.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 6.7% · Q4 12.8% · 4Q avg 6.0%
Percentage of long-stay residents who lose too much weight	5.3%	5.9% 0.6 pts better	5.4% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.9% · Q3 5.7% · Q4 5.4% · 4Q avg 5.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.7%	20.7% 1 pts worse	19.6% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 18.3% · Q3 20.0% · Q4 24.5% · 4Q avg 21.7%
Percentage of long-stay residents who received an antipsychotic medication	19.6%	21.4% 1.8 pts better	16.7% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 17.9% · Q3 21.7% · Q4 16.4% · 4Q avg 19.6% · 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	12.0%	17.9% 5.9 pts better	16.3% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 12.3% · Q3 8.2% · Q4 5.8% · 4Q avg 12.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.3%	16.2% 2.1 pts worse	14.9% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 18.6% · Q3 23.1% · Q4 13.8% · 4Q avg 18.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	1.1% 0.6 pts better	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.5% 2.5 pts better	1.7% 1.7 pts better	Long 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 long-stay residents with new or worsened bowel or bladder incontinence	27.0%	16.1% 10.9 pts worse	19.8% 7.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 41.0% · Q3 26.1% · Q4 13.3% · 4Q avg 27.0%
Percentage of long-stay residents with pressure ulcers	5.2%	6.2% 1 pts better	5.1% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 5.3% · Q3 3.9% · Q4 3.1% · 4Q avg 5.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	30.1%	80.4% 50.3 pts worse	81.7% 51.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 54.2% · Q2 41.2% · Q3 18.2% · Q4 4.3% · 4Q avg 30.1%
Percentage of short-stay residents who had an outpatient emergency department visit	20.4%	12.2% 8.2 pts worse	12.0% 8.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 23.6% · Expected 12.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	2.2% 0.8 pts better	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.8% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	34.7%	78.2% 43.5 pts worse	79.7% 45 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 34.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.2%	24.2% 1 pts better	23.9% 0.7 pts better	Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 29.1% · Expected 29.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-11-16 · Fire 2023-11-16

8 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Cycle 2 Health 2023-01-05 · Fire 2023-01-05

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

5 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 3 Health 2019-08-08 · Fire 2019-08-08

8 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

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 2023-11-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-12-31

F · Potential for more than minimal harm 2023-11-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-31

F · Potential for more than minimal harm 2023-11-16

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-12-31

E · Potential for more than minimal harm 2023-11-16

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2023-12-31

E · Potential for more than minimal harm 2023-11-16

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-12-31

E · Potential for more than minimal harm 2023-11-16

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-12-31

D · Potential for more than minimal harm 2023-11-16

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2023-12-31

D · Potential for more than minimal harm 2023-11-16

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-12-31

D · Potential for more than minimal harm 2023-11-16

K371 · Smoke Deficiencies

Fire Safety

Have properly sized and located compartments to protect residents from smoke.

Corrected 2023-12-31

F · Potential for more than minimal harm 2023-01-05

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-02-27

F · Potential for more than minimal harm 2023-01-05

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-02-27

F · Potential for more than minimal harm 2023-01-05

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-02-27

D · Potential for more than minimal harm 2023-01-05

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-02-27

D · Potential for more than minimal harm 2023-01-05

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 2023-02-27

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-05-22

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 2025-07-01

D · Potential for more than minimal harm 2025-05-22

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-05-22

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-05-22

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-05-22

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 2025-07-01

D · Potential for more than minimal harm 2025-05-22

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-07-01

D · Potential for more than minimal harm 2023-11-16

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 2024-01-11

D · Potential for more than minimal harm 2023-11-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-11

E · Potential for more than minimal harm 2023-01-05

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 2023-02-27

E · Potential for more than minimal harm 2023-01-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-02-27

D · Potential for more than minimal harm 2023-01-05

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-02-27

D · Potential for more than minimal harm 2023-01-05

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 2023-02-27

D · Potential for more than minimal harm 2023-01-05

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-02-27

D · Potential for more than minimal harm 2023-01-05

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2023-02-27

D · Potential for more than minimal harm 2023-01-05

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2023-02-27

E · Potential for more than minimal harm 2019-08-08

F761 · Pharmacy Service Deficiencies

Health

Corrected 2019-09-22

E · Potential for more than minimal harm 2019-08-08

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 2019-09-22

D · Potential for more than minimal harm 2019-08-08

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 2019-09-22

D · Potential for more than minimal harm 2019-08-08

F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Corrected 2019-09-22

D · Potential for more than minimal harm 2019-08-08

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 2019-09-22

D · Potential for more than minimal harm 2019-08-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-09-22

D · Potential for more than minimal harm 2019-08-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-09-22

B · Minimal harm 2019-08-08

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2019-09-22

Penalties and ownership

What sits behind the stars

Ownership

Ga Pcnh Holdco LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2024-04-01

Brass Ga Tr

5% Or Greater Indirect Ownership Interest · Organization

20% 1 facilities 2024-04-01

Gem Bsd Ga Tr

5% Or Greater Indirect Ownership Interest · Organization

20% 1 facilities 2024-04-01

Gold Ga Tr

5% Or Greater Indirect Ownership Interest · Organization

20% 1 facilities 2024-04-01

Silver Ga Tr

5% Or Greater Indirect Ownership Interest · Organization

20% 1 facilities 2024-04-01

Cooper Ga Tr

5% Or Greater Indirect Ownership Interest · Organization

8% 1 facilities 2024-04-01

Bailey, Takeciona