Cycle 1
Health 2025-05-02 · Fire 2025-05-02
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Leesburg, GA
Lee County Health And Rehabilitation
3-star overall rating with 3-star inspections with $16,800 in total fines with 3 fire-safety deficiencies in the latest cycle
214 Main Street, Leesburg, GA
(229) 759-9236
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
60
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1996-08-13
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
0.67
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,836
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.54
Baseline 22.36% · Performance 20.74% · Measure score 2.54 · Achievement 1.50 · Improvement 2.54
Healthcare-associated infections
0
Baseline 8.28% · Performance 9.76% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.05
Baseline 64.81% · Performance 30.77% · Measure score 8.05 · Achievement 8.05 · Improvement 8.02
Adjusted total nurse staffing
3.36
Baseline 3.26 hours · Performance 4.03 hours · Measure score 3.36 · Achievement 3.36 · Improvement 2.55
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 6.92% |
| Discharge to community | 55.83% |
50.57%
5.3 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 51.92% · Lower 95% interval 40.12% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.5% |
95.27%
2.2 pts better
|
Numerator 39 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 43.33% |
53.69%
10.4 pts worse
|
Numerator 13 · Denominator 30 |
| Discharge mobility score | 36.67% |
50.94%
14.3 pts worse
|
Numerator 11 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 2 · Denominator 40 · Adjusted rate 3.64% |
| Healthcare-associated infections requiring hospitalization | 9.76% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 18.75% · Lower 95% interval 5.4% |
| Staff COVID-19 vaccination coverage | 1.25% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 80 |
| Staff flu vaccination coverage | 57.14% |
42%
15.1 pts better
|
Numerator 52 · Denominator 91 |
| Discharge function score | 56.67% |
56.45%
0.2 pts better
|
Numerator 17 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 19 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 5 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.6% |
3.2%
0.4 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.6% · Q3 3.4% · Q4 3.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 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 who lose too much weight | 5.7% |
5.9%
0.2 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 6.2% · Q3 4.0% · Q4 8.7% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
20.7%
0.8 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 24.0% · Q3 19.2% · Q4 16.7% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
21.4%
1.4 pts better
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 19.0% · Q3 19.0% · Q4 23.3% · 4Q avg 20.0% · 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 | 23.4% |
17.9%
5.5 pts worse
|
16.3%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.2% |
16.2%
14 pts worse
|
14.9%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 26.8% · Q3 38.6% · Q4 26.8% · 4Q avg 30.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.2% |
1.1%
3.1 pts worse
|
1.0%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.2% · Q3 3.4% · Q4 2.9% · 4Q avg 4.2% · 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 0.0% · Q3 7.1% · Q4 11.8% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.1% |
16.1%
3 pts worse
|
19.8%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 10.5% · Q3 17.2% · Q4 17.1% · 4Q avg 19.1% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
6.2%
0.9 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 8.4% · Q3 6.6% · Q4 6.9% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
80.4%
19.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 33.3% |
12.2%
21.1 pts worse
|
12.0%
21.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.3% · Observed 34.6% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.2%
0.6 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
78.2%
13.8 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
24.2%
1.1 pts better
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 23.1% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-12 · Fire 2023-03-12
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-09-23 · Fire 2021-09-23
3 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
D · Potential for more than minimal harm
2025-05-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-05-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-19
F · Potential for more than minimal harm
2023-03-12
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-04-10
F · Potential for more than minimal harm
2023-03-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-03-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-10
Inspection history
Recent health citations
J · Immediate jeopardy
2024-04-18
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 2024-05-16
J · Immediate jeopardy
2024-04-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-04-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-16
D · Potential for more than minimal harm
2023-03-12
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 2023-04-10
D · Potential for more than minimal harm
2023-03-12
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 2023-04-10
D · Potential for more than minimal harm
2023-03-12
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 2023-04-10
D · Potential for more than minimal harm
2023-03-12
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 2023-04-10
D · Potential for more than minimal harm
2023-03-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-10
D · Potential for more than minimal harm
2021-09-23
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 2021-11-07
D · Potential for more than minimal harm
2021-09-23
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 2021-11-07
D · Potential for more than minimal harm
2021-09-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-07
Penalties and ownership
What sits behind the stars
$5,346
2024-04-18
Fine
Fine · fine $5,346
Fine
$11,454
2024-04-18
Fine
Fine · fine $11,454
Fine
Ownership
Clinical Services Inc
Operational/Managerial Control · Organization
Hill, Stacey
Operational/Managerial Control · Individual
Johnston, Joseph
Operational/Managerial Control · Individual
Satchell, Michael
Operational/Managerial Control · Individual
Talley, Tiffany
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Pruitthealth - Palmyra
Albany, GA
1-star overall rating with 1-star inspections with Special Focus status with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Wynfield Park Health And Rehabilitation
Albany, GA
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#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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