Vidalia, GA

Meadows Park Health And Rehabilitation

5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

119 Meadows Parkway West, Vidalia, GA

(912) 403-3400

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

75

Certified beds

Average residents

73

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Ethica Health

Operator or chain grouping

Approved since

2015-06-12

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

No

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.62

Registered nurse staffing · state 0.49 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 0.93 · national 0.87

Aide hours / resident day

2.30

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.74

All reported nurse hours · state 3.57 · national 3.89

Licensed hours

1.44

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

3.24

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.44

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.64

CMS adjusted RN staffing hours

Adjusted total hours

3.90

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

29%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,951

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

Performance score

38

Composite VBP score used to determine payment impact.

Payment multiplier

0.9911

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.24

Baseline 22.89% · Performance 20.11% · Measure score 4.24 · Achievement 2.85 · Improvement 4.24

Healthcare-associated infections

0

Baseline 5.84% · Performance 8.22% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

7.66

Baseline 49.25% · Performance 32.35% · Measure score 7.66 · Achievement 7.66 · Improvement 6.43

Adjusted total nurse staffing

3.30

Baseline 4.45 hours · Performance 4.02 hours · Measure score 3.30 · Achievement 3.30 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.47%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 156 · Observed rate 10.9% · Lower 95% interval 8.65%
Discharge to community	59.83%	50.57% 9.3 pts better	Better than the National Rate · Eligible stays 135 · Observed rate 60.74% · Lower 95% interval 53.18%
Medicare spending per beneficiary	1.08	1.02 0.1 pts worse
Drug regimen review with follow-up	95.45%	95.27% 0.2 pts better	Numerator 63 · Denominator 66
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 66
Discharge self-care score	34.55%	53.69% 19.1 pts worse	Numerator 19 · Denominator 55
Discharge mobility score	32.73%	50.94% 18.2 pts worse	Numerator 18 · Denominator 55
Pressure ulcers or injuries, new or worsened	4.55%	2.29% 2.3 pts worse	Numerator 3 · Denominator 66 · Adjusted rate 4.71%
Healthcare-associated infections requiring hospitalization	8.22%	7.12% 1.1 pts worse	No Different than the National Rate · Eligible stays 70 · Observed rate 8.57% · Lower 95% interval 5.07%
Staff COVID-19 vaccination coverage	1.98%	8.2% 6.2 pts worse	Numerator 2 · Denominator 101
Staff flu vaccination coverage	48.72%	42% 6.7 pts better	Numerator 57 · Denominator 117
Discharge function score	45.45%	56.45% 11 pts worse	Numerator 25 · Denominator 55
Transfer of health information to provider	96.15%	95.95% 0.2 pts better	Numerator 25 · Denominator 26
Transfer of health information to patient	91.3%	96.28% 5 pts worse	Numerator 21 · Denominator 23
Resident COVID-19 vaccinations up to date	13.51%	25.2% 11.7 pts worse	Numerator 5 · Denominator 37

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.3	2.2 0.9 pts better	1.9 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	2.0 0.8 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star
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	97.1%	95.0% 2.1 pts better	95.5% 1.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1%
Percentage of long-stay residents experiencing one or more falls with major injury	5.8%	3.2% 2.6 pts worse	3.3% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.5% · Q3 6.6% · Q4 9.5% · 4Q avg 5.8% · 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	5.1%	5.9% 0.8 pts better	5.4% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.8% · Q3 13.2% · Q4 1.8% · 4Q avg 5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	24.4%	20.7% 3.7 pts worse	19.6% 4.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 22.2% · Q3 21.8% · Q4 30.4% · 4Q avg 24.4%
Percentage of long-stay residents who received an antipsychotic medication	17.3%	21.4% 4.1 pts better	16.7% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 16.3% · Q3 18.4% · Q4 13.7% · 4Q avg 17.3% · 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	12.6%	17.9% 5.3 pts better	16.3% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 12.6% · Q3 16.6% · Q4 8.4% · 4Q avg 12.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.1%	16.2% 4.1 pts better	14.9% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 15.7% · Q3 11.8% · Q4 7.7% · 4Q avg 12.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	1.1% 0.7 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.6%	2.5% 1.1 pts worse	1.7% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 3.4% · Q4 4.8% · 4Q avg 3.6% · 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 7.9% · Q2 12.8% · Q3 14.8% · Q4 11.2% · 4Q avg 11.6%
Percentage of long-stay residents with pressure ulcers	5.0%	6.2% 1.2 pts better	5.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.6% · Q3 2.5% · Q4 7.0% · 4Q avg 5.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.1%	80.4% 18.7 pts better	81.7% 17.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1%
Percentage of short-stay residents who had an outpatient emergency department visit	2.2%	12.2% 10 pts better	12.0% 9.8 pts better	Short Stay · 20240701-20250630 · Adjusted 2.2% · Observed 2.0% · Expected 10.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.6%	2.2% 0.4 pts worse	1.6% 1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.1% · Q3 2.4% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.4%	78.2% 16.2 pts better	79.7% 14.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	9.3%	24.2% 14.9 pts better	23.9% 14.6 pts better	Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 7.8% · Expected 20.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-22 · Fire 2025-05-22

2 health deficiencies

Top issue: Infection Control (1 deficiency)

4 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2024-01-28 · Fire 2024-01-28

0 health deficiencies

No concentrated health issue counts in this cycle.

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2022-04-10 · Fire 2022-04-10

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

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 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

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-06-27

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 2025-06-27

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

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-06-27

D · Potential for more than minimal harm 2024-01-28

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 2024-02-05

Inspection history

Recent health citations

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

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 2025-07-31

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

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-31

D · Potential for more than minimal harm 2022-04-10

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2022-05-25

D · Potential for more than minimal harm 2022-04-10

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 2022-05-25

Penalties and ownership