Cycle 1
Health 2024-09-15 · Fire 2024-09-15
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Montezuma, GA
Montezuma Health And Rehabilitation
4-star overall rating with 4-star inspections with $24,284 in total fines with 1 fire-safety deficiencies in the latest cycle
506 Sumter St, Montezuma, GA
(478) 472-8168
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1989-07-01
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
0.59
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.77
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,054
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9882
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.39
Baseline 73.02% · Performance 54.29% · Measure score 3.39 · Achievement 2.30 · Improvement 3.39
Adjusted total nurse staffing
3.44
Baseline 3.79 hours · Performance 4.06 hours · Measure score 3.44 · Achievement 3.44 · Improvement 0.86
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.41% |
8.2%
5.8 pts worse
|
Numerator 2 · Denominator 83 |
| Staff flu vaccination coverage | 68.63% |
42%
26.6 pts better
|
Numerator 70 · Denominator 102 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · 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 | 97.4% |
91.2%
6.2 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.5% · Q3 97.1% · Q4 95.9% · 4Q avg 97.4% |
| 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 | 2.2% |
3.2%
1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 2.9% · Q4 2.7% · 4Q avg 2.2% · 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 | 5.2% |
5.9%
0.7 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.2% · Q3 7.7% · Q4 7.5% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.6% |
20.7%
0.1 pts better
|
19.6%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 19.0% · Q3 24.6% · Q4 20.6% · 4Q avg 20.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.1% |
21.4%
14.7 pts worse
|
16.7%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 42.3% · Q3 37.9% · Q4 33.9% · 4Q avg 36.1% · 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 | 13.7% |
17.9%
4.2 pts better
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.3% |
16.2%
14.1 pts worse
|
14.9%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 48.1% · Q3 24.5% · Q4 25.9% · 4Q avg 30.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.1%
0.3 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.0% · Q4 0.9% · 4Q avg 0.8% · 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 0.0% · Q2 1.5% · Q3 1.5% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.3% |
16.1%
8.8 pts better
|
19.8%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.5% · Q3 9.7% · Q4 5.9% · 4Q avg 7.3% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
6.2%
1.6 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.6% · Q3 7.3% · Q4 9.8% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
80.4%
2.4 pts worse
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.1% · Q2 80.6% · Q3 80.6% · Q4 81.5% · 4Q avg 78.0% |
| 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 assessed and appropriately given the seasonal influenza vaccine | 81.2% |
78.2%
3 pts better
|
79.7%
1.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-02 · Fire 2023-07-02
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-03-03 · Fire 2022-03-03
3 health deficiencies
Top issue: Quality of Life and Care (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
2024-09-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-18
E · Potential for more than minimal harm
2023-07-02
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-07-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-18
G · Actual harm
2023-11-30
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 2023-12-29
G · Actual harm
2023-11-30
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 2023-12-29
D · Potential for more than minimal harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-07-02
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 2023-08-01
E · Potential for more than minimal harm
2023-07-02
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 2023-08-01
D · Potential for more than minimal harm
2023-07-02
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-08-01
Penalties and ownership
What sits behind the stars
$3,728
2023-11-30
Fine
Fine · fine $3,728
Fine
$5,365
2023-11-30
Fine
Fine · fine $5,365
Fine
$6,500
2023-11-30
Fine
Fine · fine $6,500
Fine
$3,728
2023-07-02
Fine
Fine · fine $3,728
Fine
$4,963
2023-07-02
Fine
Fine · fine $4,963
Fine
Ownership
Clinical Services Inc
Operational/Managerial Control · Organization
Mims, Debra
Operational/Managerial Control · Individual
Pittman, Jacqueline
Operational/Managerial Control · Individual
Satchell, Michael
Operational/Managerial Control · Individual
Walker, Shawanda
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Oaks Nursing Home, Inc, The
Marshallville, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Miona Geriatric & Dementia Center
Ideal, GA
5-star overall rating with 5-star inspections
#3
Fort Valley Health And Rehab
Fort Valley, GA
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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