Cycle 1
Health 2024-07-18 · Fire 2024-07-18
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lake City, GA
Lake City Center for Nursing and Healing LLC
1-star overall rating with 2-star inspections with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
2055 Rex Road, Lake City, GA
(404) 361-1028
Overall
1 / 5
CMS overall stars
Health inspections
2 / 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
242
Certified beds
Average residents
206
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Norbert Bennett & Donald Denz
Operator or chain grouping
Approved since
1993-01-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
29 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 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
0.86
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.08
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.58
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,153
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.51% · Performance 22.04% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.42% · Performance 10.01% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.71
Baseline 40.38% · Performance 44.44% · Measure score 4.71 · Achievement 4.71 · Improvement 0
Adjusted total nurse staffing
0.76
Baseline 2.55 hours · Performance 2.96 hours · Measure score 0.76 · Achievement 0 · Improvement 0.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 16% · Lower 95% interval 7.93% |
| Discharge to community | 47.11% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 30% · Lower 95% interval 31.36% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 56% |
95.27%
39.3 pts worse
|
Numerator 28 · Denominator 50 |
| Falls with major injury | 8% |
0.77%
7.2 pts worse
|
Numerator 4 · Denominator 50 |
| Discharge self-care score | 46.67% |
53.69%
7 pts worse
|
Numerator 14 · Denominator 30 |
| Discharge mobility score | 43.33% |
50.94%
7.6 pts worse
|
Numerator 13 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 2 · Denominator 50 · Adjusted rate 3.19% |
| Healthcare-associated infections requiring hospitalization | 10.01% |
7.12%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 28.57% · Lower 95% interval 6.13% |
| Staff COVID-19 vaccination coverage | 1.69% |
8.2%
6.5 pts worse
|
Numerator 4 · Denominator 237 |
| Staff flu vaccination coverage | 23.27% |
42%
18.7 pts worse
|
Numerator 57 · Denominator 245 |
| Discharge function score | 46.67% |
56.45%
9.8 pts worse
|
Numerator 14 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| 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 | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.2
0.4 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.0
1.1 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 54.1% |
91.2%
37.1 pts worse
|
93.4%
39.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.7% · Q2 54.3% · Q3 56.8% · Q4 54.8% · 4Q avg 54.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.6% |
95.0%
6.4 pts worse
|
95.5%
6.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| 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 2.9% · Q2 1.5% · Q3 1.6% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
9.6%
8.5 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.6% · Q3 0.6% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.9%
2.1 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.2% · Q3 4.6% · Q4 2.9% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
20.7%
8 pts better
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 16.1% · Q3 11.4% · Q4 11.2% · 4Q avg 12.7% |
| 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 | 13.7% |
17.9%
4.2 pts better
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 18.4% · Q3 8.2% · Q4 13.0% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
16.2%
6.9 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.3% · Q3 8.2% · Q4 9.4% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
1.1%
1 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · 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 1.5% · Q2 1.0% · Q3 1.1% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.4% |
16.1%
2.7 pts better
|
19.8%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 14.6% · Q3 16.2% · Q4 12.7% · 4Q avg 13.4% |
| Percentage of long-stay residents with pressure ulcers | 11.4% |
6.2%
5.2 pts worse
|
5.1%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 12.0% · Q3 11.3% · Q4 13.2% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.6% |
80.4%
46.8 pts worse
|
81.7%
48.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 27.8% · Q3 37.4% · Q4 41.9% · 4Q avg 33.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
12.2%
1.8 pts worse
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 17.1% · Expected 13.6% · 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 2.2% · Q4 3.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 36.4% |
78.2%
41.8 pts worse
|
79.7%
43.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 36.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.3% |
24.2%
6.1 pts worse
|
23.9%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 34.1% · Expected 26.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-28 · Fire 2022-10-28
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-07-18 · Fire 2019-07-18
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-18
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-07-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-07-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-07-18
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 2024-09-01
E · Potential for more than minimal harm
2024-07-18
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-01
E · Potential for more than minimal harm
2022-10-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-19
D · Potential for more than minimal harm
2022-10-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-19
D · Potential for more than minimal harm
2022-10-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-19
E · Potential for more than minimal harm
2019-07-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-09-01
E · Potential for more than minimal harm
2019-07-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-09-01
D · Potential for more than minimal harm
2019-07-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-09-01
D · Potential for more than minimal harm
2019-07-18
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-09-01
D · Potential for more than minimal harm
2019-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-07
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 2026-02-14
F · Potential for more than minimal harm
2024-07-18
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-07-18
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 2024-09-01
E · Potential for more than minimal harm
2024-07-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
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 2024-09-01
D · Potential for more than minimal harm
2024-07-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-01
E · Potential for more than minimal harm
2022-10-28
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 2022-12-19
D · Potential for more than minimal harm
2022-10-28
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 2022-12-19
D · Potential for more than minimal harm
2022-10-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-19
D · Potential for more than minimal harm
2022-10-28
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-12-19
D · Potential for more than minimal harm
2022-10-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-19
D · Potential for more than minimal harm
2022-10-28
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 2022-12-19
F · Potential for more than minimal harm
2019-07-18
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 2019-09-01
D · Potential for more than minimal harm
2019-07-18
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 2019-09-01
D · Potential for more than minimal harm
2019-07-18
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 2019-09-01
D · Potential for more than minimal harm
2019-07-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-09-01
Penalties and ownership
What sits behind the stars
Ownership
D&N, LLC
5% Or Greater Direct Ownership Interest · Organization
Dtd Hc, LLC
5% Or Greater Direct Ownership Interest · Organization
Bennett, Norbert
5% Or Greater Indirect Ownership Interest · Individual
Denz, Donald
5% Or Greater Indirect Ownership Interest · Individual
Donad T Denz Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Norbert A Bennett Irrv Tr Fbo Children
5% Or Greater Indirect Ownership Interest · Organization
Norbert A Bennett Irrv Tr Fbo Grandchildren
5% Or Greater Indirect Ownership Interest · Organization
Sarju, Paula
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Arrowhead Post Acute LLC
Jonesboro, GA
1-star overall rating with 2-star inspections with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Jonesboro Center for Nursing and Healing LLC
Jonesboro, GA
4-star overall rating with 4-star inspections with $16,801 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Riverdale Center For Nursing And Healing
Riverdale, GA
2-star overall rating with 2-star inspections with $10,050 in total fines with 6 recent health deficiencies
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