Cycle 1
Health 2025-01-30 · Fire 2025-01-30
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lyons, GA
Oxley Park Health And Rehabilitation
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
181 Oxley Drive, Lyons, GA
(912) 526-6336
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1989-09-01
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
0.55
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.85
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
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,770
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.24
Performance 19.93% · Measure score 3.24 · Achievement 3.24 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.46
Performance 6.80% · Measure score 3.46 · Achievement 3.46 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 42.86% · Performance 62.20% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.34
Baseline 3.88 hours · Performance 3.74 hours · Measure score 2.34 · Achievement 2.34 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.42% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 5.41% · Lower 95% interval 6.11% |
| Discharge to community | 49.83% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 44.68% · Lower 95% interval 37.17% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.05% |
95.27%
0.8 pts better
|
Numerator 73 · Denominator 76 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 76 |
| Discharge self-care score | 46.94% |
53.69%
6.8 pts worse
|
Numerator 23 · Denominator 49 |
| Discharge mobility score | 44.9% |
50.94%
6 pts worse
|
Numerator 22 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 76 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.8% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 4.35% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 112 |
| Staff flu vaccination coverage | 73.88% |
42%
31.9 pts better
|
Numerator 99 · Denominator 134 |
| Discharge function score | 53.06% |
56.45%
3.4 pts worse
|
Numerator 26 · Denominator 49 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.22% |
96.28%
0.9 pts better
|
Numerator 35 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 21.05% |
25.2%
4.1 pts worse
|
Numerator 8 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
91.2%
7.5 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.7% · Q3 100.0% · Q4 100.0% · 4Q avg 98.7% |
| 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 | 3.2% |
3.2%
About the same
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.9% · Q3 1.2% · Q4 2.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
9.6%
6.8 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.3% · Q3 1.4% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 11.4% |
5.9%
5.5 pts worse
|
5.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 12.5% · Q3 11.6% · Q4 6.3% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.2% |
20.7%
6.5 pts worse
|
19.6%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 29.7% · Q3 25.7% · Q4 28.8% · 4Q avg 27.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
21.4%
1.8 pts better
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 22.4% · Q3 19.6% · Q4 14.0% · 4Q avg 19.6% · 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 | 11.0% |
17.9%
6.9 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 16.0% · Q3 3.7% · Q4 6.9% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
16.2%
1.7 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 10.3% · Q3 16.7% · Q4 16.1% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.1%
0.1 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.3% · Q3 1.2% · Q4 1.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.5%
0.4 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 5.3% · Q3 2.5% · Q4 2.7% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.2% |
16.1%
3.9 pts better
|
19.8%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 7.6% · Q3 11.6% · Q4 18.9% · 4Q avg 12.2% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
6.2%
1.1 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.8% · Q3 5.5% · Q4 6.9% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
80.4%
9.8 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 96.2% · Q3 94.4% · Q4 77.6% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 27.3% |
12.2%
15.1 pts worse
|
12.0%
15.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 25.0% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.6% |
2.2%
2.4 pts worse
|
1.6%
3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.5% · Q3 5.3% · Q4 2.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.5% |
78.2%
14.3 pts better
|
79.7%
12.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
24.2%
5.6 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 17.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-18 · Fire 2022-08-18
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-05-09 · Fire 2019-05-09
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-07
E · Potential for more than minimal harm
2022-08-18
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-10-02
D · Potential for more than minimal harm
2022-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-02
D · Potential for more than minimal harm
2022-08-18
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2022-10-02
D · Potential for more than minimal harm
2022-08-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-02
D · Potential for more than minimal harm
2019-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-30
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 2025-03-07
D · Potential for more than minimal harm
2025-01-30
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 2025-03-07
D · Potential for more than minimal harm
2025-01-30
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 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
Penalties and ownership
What sits behind the stars
Ownership
Clinical Services Inc
Operational/Managerial Control · Organization
Hodges, Kimberly
Operational/Managerial Control · Individual
Horton, Zasha
Operational/Managerial Control · Individual
Morris, Amy
Operational/Managerial Control · Individual
Patel, Maulikkumar
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Oaks - Bethany Skilled Nursing, The
Vidalia, GA
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Meadows Park Health And Rehabilitation
Vidalia, GA
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Tattnall Healthcare Center
Reidsville, GA
1-star overall rating with 2-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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