4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Monroe, GA
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1865 Bold Springs Road, Monroe, GA
(770) 267-8677
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
175
Certified beds
Average residents
157
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Michael Feist
Operator or chain grouping
Approved since
1993-11-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 3 health / 2 staffing / 4 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
RN hours / resident day
0.46
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.34
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
76%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
11,866
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.78
Baseline 20.89% · Performance 21.07% · Measure score 0.78 · Achievement 0.78 · Improvement 0
Healthcare-associated infections
0
Baseline 9.04% · Performance 8.89% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.84
Baseline 73.91% · Performance 52.60% · Measure score 3.84 · Achievement 2.71 · Improvement 3.84
Adjusted total nurse staffing
1.35
Baseline 3.10 hours · Performance 3.46 hours · Measure score 1.35 · Achievement 1.35 · Improvement 0.85
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.26% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 437 · Observed rate 10.3% · Lower 95% interval 8.21% |
| Discharge to community | 60.6% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 459 · Observed rate 52.07% · Lower 95% interval 54.3% |
| Medicare spending per beneficiary | 1.41 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 95.62% |
95.27%
0.4 pts better
|
Numerator 437 · Denominator 457 |
| Falls with major injury | 0.66% |
0.77%
0.1 pts better
|
Numerator 3 · Denominator 457 |
| Discharge self-care score | 46.23% |
53.69%
7.5 pts worse
|
Numerator 141 · Denominator 305 |
| Discharge mobility score | 49.84% |
50.94%
1.1 pts worse
|
Numerator 152 · Denominator 305 |
| Pressure ulcers or injuries, new or worsened | 3.95% |
2.29%
1.7 pts worse
|
Numerator 18 · Denominator 456 · Adjusted rate 3.49% |
| Healthcare-associated infections requiring hospitalization | 8.89% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 334 · Observed rate 9.58% · Lower 95% interval 6.84% |
| Staff COVID-19 vaccination coverage | 4.4% |
8.2%
3.8 pts worse
|
Numerator 11 · Denominator 250 |
| Staff flu vaccination coverage | 6.84% |
42%
35.2 pts worse
|
Numerator 16 · Denominator 234 |
| Discharge function score | 53.44% |
56.45%
3 pts worse
|
Numerator 163 · Denominator 305 |
| Transfer of health information to provider | 98.31% |
95.95%
2.4 pts better
|
Numerator 232 · Denominator 236 |
| Transfer of health information to patient | 98.9% |
96.28%
2.6 pts better
|
Numerator 179 · Denominator 181 |
| Resident COVID-19 vaccinations up to date | 24.32% |
25.2%
0.9 pts worse
|
Numerator 63 · Denominator 259 |
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 2.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.2%
8.2 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.3% |
95.0%
8.7 pts worse
|
95.5%
9.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.3% |
| 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 3.4% · Q2 8.0% · Q3 6.4% · Q4 5.3% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.2% |
9.6%
6.6 pts worse
|
11.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.3% · Q3 38.1% · Q4 21.9% · 4Q avg 16.2% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
5.9%
0.7 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.7% · Q3 6.2% · Q4 10.2% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
20.7%
1.2 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 19.0% · Q3 21.7% · Q4 17.7% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
21.4%
7.7 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 17.4% · Q3 11.3% · Q4 9.3% · 4Q avg 13.7% · 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 | 3.8% |
17.9%
14.1 pts better
|
16.3%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.3% · Q4 8.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
16.2%
6.4 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 16.9% · Q3 9.0% · Q4 8.3% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.5%
0.1 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.4% · Q4 5.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.5% |
16.1%
9.6 pts better
|
19.8%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 8.7% · Q3 6.1% · Q4 1.3% · 4Q avg 6.5% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
6.2%
1.4 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.4% · Q3 8.5% · Q4 6.5% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
80.4%
12.7 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 92.0% · Q3 95.4% · Q4 93.5% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
12.2%
1.3 pts worse
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 14.2% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.2%
0.7 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.9% · Q3 2.1% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.3% |
78.2%
6.1 pts better
|
79.7%
4.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
24.2%
2.2 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 27.2% · Expected 29.4% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-23
Fire Safety
Install proper backup exit lighting.
Corrected 2023-03-06
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-06
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-03-06
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-23
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 2025-05-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-23
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 2025-05-23
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-13
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2024-04-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-06
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-06
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-03-06
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-11-01
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2021-11-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
5% Or Greater Indirect Ownership Interest · Organization
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