Cycle 1
Health 2025-05-22 · Fire 2025-05-22
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Saint Simons Island, GA
Marsh's Edge
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
111 Renegar Way, Saint Simons Island, GA
(912) 291-2000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
10
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Senior Living Communities
Operator or chain grouping
Approved since
2007-04-25
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 5 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
1.94
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.92
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
4.45
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
8.31
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
3.85
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
7.64
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.46
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
2.01
CMS adjusted RN staffing hours
Adjusted total hours
8.64
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 47% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.89% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 16.67% · Lower 95% interval 9.51% |
| Discharge to community | 51.89% |
50.57%
1.3 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 50% · Lower 95% interval 41.71% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | 10% |
53.69%
43.7 pts worse
|
Numerator 2 · Denominator 20 |
| Discharge mobility score | 30% |
50.94%
20.9 pts worse
|
Numerator 6 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · 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 45 |
| Staff flu vaccination coverage | 8.7% |
42%
33.3 pts worse
|
Numerator 4 · Denominator 46 |
| Discharge function score | 30% |
56.45%
26.5 pts worse
|
Numerator 6 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.9%
5.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
20.7%
1.7 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
16.1%
7.3 pts worse
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.2%
6.2 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
12.2%
2.1 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 8.3% · Expected 9.2% · Used in QM five-star |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
24.2%
1.3 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 20.8% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-29 · Fire 2023-01-29
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-08-12 · Fire 2021-08-12
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-06
F · Potential for more than minimal harm
2023-01-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-01-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-01-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-01-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-22
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 2025-07-06
F · Potential for more than minimal harm
2023-01-29
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 2023-03-13
Penalties and ownership
What sits behind the stars
Ownership
Senior Living Commuities LLC
5% Or Greater Direct Ownership Interest · Organization
Thompson, Donald
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Maxwell Group, Inc.
Operational/Managerial Control · Organization
Thompson, Benjamin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Heritage Oaks
Saint Simons Island, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Senior Care Center - Brunswick
Brunswick, GA
1-star overall rating with 1-star inspections with $16,801 in total fines with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Sears Manor Nursing Home
Brunswick, GA
2-star overall rating with 2-star inspections with $14,892 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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