Cycle 1
Health 2025-08-21 · Fire 2025-08-21
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Macon, GA
Macon Rehabilitation And Healthcare
2-star overall rating with 3-star inspections with $31,738 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
505 Coliseum Drive, Macon, GA
(478) 743-8687
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Wellington Health Care Services
Operator or chain grouping
Approved since
1989-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 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
0.24
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
2.89
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.01
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.30
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.21
CMS adjusted RN staffing hours
Adjusted total hours
2.60
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
57%
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
8,645
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9840
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.09
Baseline 19.31% · Performance 19.53% · Measure score 4.09 · Achievement 4.09 · Improvement 0
Healthcare-associated infections
0
Baseline 7.37% · Performance 8.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.14
Performance 42.68% · Measure score 5.14 · Achievement 5.14 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.21
Baseline 2.60 hours · Performance 3.14 hours · Measure score 1.21 · Achievement 0 · Improvement 1.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.12% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 10.42% · Lower 95% interval 7.15% |
| Discharge to community | 44.04% |
50.57%
6.5 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 25.71% · Lower 95% interval 30.53% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 69 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 35.29% |
53.69%
18.4 pts worse
|
Numerator 12 · Denominator 34 |
| Discharge mobility score | 29.41% |
50.94%
21.5 pts worse
|
Numerator 10 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 3 · Denominator 69 · Adjusted rate 2.62% |
| Healthcare-associated infections requiring hospitalization | 8.81% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 20% · Lower 95% interval 4.21% |
| 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 | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 41.18% |
56.45%
15.3 pts worse
|
Numerator 14 · Denominator 34 |
| Transfer of health information to provider | 97.06% |
95.95%
1.1 pts better
|
Numerator 33 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.62% |
25.2%
3.6 pts worse
|
Numerator 8 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.2
1.1 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.9% |
91.2%
15.3 pts worse
|
93.4%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 87.0% · Q3 66.3% · Q4 60.5% · 4Q avg 75.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
95.0%
1.9 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.2%
About the same
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.3% · Q3 2.4% · Q4 1.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
9.6%
8.3 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.2% · Q3 1.4% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.9%
4.6 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 1.4% · Q4 1.3% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
20.7%
3.9 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 17.3% · Q3 17.1% · Q4 15.9% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.3% |
21.4%
10.1 pts better
|
16.7%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 10.7% · Q3 10.9% · Q4 12.0% · 4Q avg 11.3% · 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 | 10.2% |
17.9%
7.7 pts better
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 4.2% · Q3 8.6% · Q4 12.8% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
16.2%
6.4 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 1.6% · Q3 11.9% · Q4 13.4% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.1%
0.6 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.6% · Q3 1.8% · Q4 2.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.5%
2.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.6% |
16.1%
4.5 pts better
|
19.8%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 7.1% · Q3 4.4% · Q4 13.7% · 4Q avg 11.6% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
6.2%
3.6 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 9.8% · Q3 9.9% · Q4 7.7% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 15.5% |
80.4%
64.9 pts worse
|
81.7%
66.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.3% · Q3 8.4% · Q4 4.8% · 4Q avg 15.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.8% |
12.2%
3.6 pts worse
|
12.0%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 19.0% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
2.2%
0.9 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 9.1% · Q3 0.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 31.6% |
78.2%
46.6 pts worse
|
79.7%
48.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 31.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
24.2%
0.7 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 33.3% · Expected 31.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-21 · Fire 2024-04-21
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-07-31 · Fire 2022-07-31
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-05
F · Potential for more than minimal harm
2022-07-31
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-02
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 2025-10-05
D · Potential for more than minimal harm
2025-09-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-05
F · Potential for more than minimal harm
2025-08-21
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 2025-10-05
D · Potential for more than minimal harm
2025-08-21
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 2025-10-05
D · Potential for more than minimal harm
2025-08-21
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-10-05
D · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-05
E · Potential for more than minimal harm
2024-04-21
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 2024-06-05
E · Potential for more than minimal harm
2024-04-21
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 2024-06-05
D · Potential for more than minimal harm
2024-04-21
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 2024-06-05
D · Potential for more than minimal harm
2024-04-21
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 2024-06-05
D · Potential for more than minimal harm
2024-04-21
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-04-21
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-04-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-02-14
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-03-30
D · Potential for more than minimal harm
2024-02-14
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 2024-03-30
F · Potential for more than minimal harm
2022-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-31
E · Potential for more than minimal harm
2022-07-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-08-31
E · Potential for more than minimal harm
2022-07-31
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 2022-08-31
E · Potential for more than minimal harm
2022-07-31
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-31
E · Potential for more than minimal harm
2022-07-31
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 2022-08-31
D · Potential for more than minimal harm
2022-07-31
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 2022-08-31
D · Potential for more than minimal harm
2022-07-31
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 2022-08-31
D · Potential for more than minimal harm
2022-07-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-31
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 2022-08-31
D · Potential for more than minimal harm
2022-07-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-31
Penalties and ownership
What sits behind the stars
$4,587
2023-08-28
Fine
Fine · fine $4,587
Fine
$4,235
2023-08-21
Fine
Fine · fine $4,235
Fine
$3,882
2023-08-14
Fine
Fine · fine $3,882
Fine
$3,529
2023-08-07
Fine
Fine · fine $3,529
Fine
$8,469
2023-07-17
Fine
Fine · fine $8,469
Fine
$2,098
2023-06-12
Fine
Fine · fine $2,098
Fine
$1,764
2023-06-05
Fine
Fine · fine $1,764
Fine
$3,174
2023-05-15
Fine
Fine · fine $3,174
Fine
Ownership
Whs Aps Holding Company Ii, LLC
5% Or Greater Direct Ownership Interest · Organization
Andrews, James
5% Or Greater Indirect Ownership Interest · Individual
Andrews, James
Operational/Managerial Control · Individual
Andrews, James
Corporate Officer · Individual
Andwell Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Clements, Jacquelyn
W-2 Managing Employee · Individual
Parkwell Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Stafford, Annette
Operational/Managerial Control · Individual
Stafford, Annette
Corporate Officer · Individual
Staffwell Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Wellington Healthcare Services- Aps I, LLC
5% Or Greater Indirect Ownership Interest · Organization
Whs Aps Holding Company I, LLC
5% Or Greater Indirect Ownership Interest · Organization
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#2
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4-star overall rating with 4-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
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