6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Elberton, GA
1-star overall rating with 2-star inspections with $30,309 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2117 Dr George Ward Road, Elberton, GA
(706) 283-3335
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
67
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.22
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.57
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
2.54
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.96
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.32
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
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
2.34
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
10,005
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
2.86
Baseline 7.59% · Performance 6.98% · Measure score 2.86 · Achievement 2.86 · Improvement 1.86
Total nurse turnover
3.66
Performance 48.72% · Measure score 3.66 · Achievement 3.66 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.01 hours · Performance 3.14 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| 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 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 1 · Denominator 21 · Adjusted rate 4.76% |
| Healthcare-associated infections requiring hospitalization | 6.98% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.39% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.2
0.3 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.0
0.3 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 62.4% |
91.2%
28.8 pts worse
|
93.4%
31 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.2% · Q2 60.0% · Q3 63.2% · Q4 56.1% · 4Q avg 62.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.4% |
95.0%
8.6 pts worse
|
95.5%
9.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.2%
2.7 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.5% · Q3 5.3% · Q4 5.3% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.0% |
9.6%
12.4 pts worse
|
11.4%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 14.8% · Q3 19.3% · Q4 30.9% · 4Q avg 22.0% |
| Percentage of long-stay residents who lose too much weight | 10.1% |
5.9%
4.2 pts worse
|
5.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 14.0% · Q3 9.5% · Q4 10.4% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.4% |
20.7%
2.7 pts worse
|
19.6%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 24.4% · Q3 23.4% · Q4 26.5% · 4Q avg 23.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
21.4%
3.5 pts better
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 11.1% · Q3 23.7% · Q4 23.1% · 4Q avg 17.9% · 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 | 31.4% |
17.9%
13.5 pts worse
|
16.3%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 61.1% · Q3 27.5% · Q4 5.4% · 4Q avg 31.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.0% |
16.2%
13.8 pts worse
|
14.9%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 44.2% · Q3 42.2% · Q4 18.8% · 4Q avg 30.0% · 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 0.0% · Q2 1.7% · Q3 0.0% · Q4 1.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.5%
0.3 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 1.9% · Q4 5.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.3% |
16.1%
1.2 pts worse
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 19.6% · Q3 15.5% · Q4 15.4% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
6.2%
0.6 pts better
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 10.5% · Q3 5.7% · Q4 3.6% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 16.7% |
80.4%
63.7 pts worse
|
81.7%
65 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 19.2% · Q3 20.7% · Q4 9.1% · 4Q avg 16.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
12.2%
1.5 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 12.0% · Expected 12.5% · 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 assessed and appropriately given the seasonal influenza vaccine | 11.5% |
78.2%
66.7 pts worse
|
79.7%
68.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 11.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
24.2%
0.8 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 24.0% · Expected 22.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Resident Rights (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Resident Rights (5 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-09-07
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-09-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-07
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-09-07
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-07
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-07
Fire Safety
Meet other general requirements.
Corrected 2024-05-23
Fire Safety
Meet other general requirements.
Corrected 2024-05-23
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-14
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-14
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-14
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-23
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-23
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-14
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-09-15
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-09-15
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2023-09-15
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-15
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-15
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-09-15
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-02-20
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-02-20
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-02-20
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-20
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-20
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-02-20
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-02-20
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-07
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 2025-09-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-07
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-07
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-14
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-14
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-04-14
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 2024-04-14
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-14
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-04-14
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-04-14
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-14
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-14
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 2024-04-14
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 2024-04-14
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-14
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-12
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-12
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-02-20
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-02-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-20
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-02-20
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-02-20
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-02-20
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-02-20
Penalties and ownership
Fine · fine $4,017
Fine
Fine · fine $4,017
Fine
Fine · fine $6,682
Fine
Fine · fine $7,796
Fine
Fine · fine $7,797
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
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Comer, GA
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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