4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Ellijay, GA
3-star overall rating with 2-star inspections with $15,593 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1362 South Main Street, Ellijay, GA
(706) 635-7881
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
110
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Michael Feist
Operator or chain grouping
Approved since
2003-07-01
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
0.77
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
3,747
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9958
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.52
Baseline 22.40% · Performance 18.09% · Measure score 7.52 · Achievement 7.2 · Improvement 7.52
Healthcare-associated infections
6.61
Baseline 13.02% · Performance 7.32% · Measure score 6.61 · Achievement 1.72 · Improvement 6.61
Total nurse turnover
2.68
Baseline 50.00% · Performance 52.73% · Measure score 2.68 · Achievement 2.68 · Improvement 0
Adjusted total nurse staffing
0.34
Baseline 2.92 hours · Performance 3.16 hours · Measure score 0.34 · Achievement 0 · Improvement 0.34
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 298 · Observed rate 10.4% · Lower 95% interval 8.31% |
| Discharge to community | 5.61% |
50.57%
45 pts worse
|
Worse than the National Rate · Eligible stays 242 · Observed rate 0% · Lower 95% interval 3.48% |
| Medicare spending per beneficiary | 1.3 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 98.91% |
95.27%
3.6 pts better
|
Numerator 271 · Denominator 274 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 274 |
| Discharge self-care score | 67.03% |
53.69%
13.3 pts better
|
Numerator 124 · Denominator 185 |
| Discharge mobility score | 69.19% |
50.94%
18.2 pts better
|
Numerator 128 · Denominator 185 |
| Pressure ulcers or injuries, new or worsened | 0.37% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 270 · Adjusted rate 0.44% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 211 · Observed rate 7.11% · Lower 95% interval 5.06% |
| Staff COVID-19 vaccination coverage | 2.55% |
8.2%
5.6 pts worse
|
Numerator 4 · Denominator 157 |
| Staff flu vaccination coverage | 3.88% |
42%
38.1 pts worse
|
Numerator 5 · Denominator 129 |
| Discharge function score | 78.92% |
56.45%
22.5 pts better
|
Numerator 146 · Denominator 185 |
| Transfer of health information to provider | 95.07% |
95.95%
0.9 pts worse
|
Numerator 193 · Denominator 203 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 2.9% |
25.2%
22.3 pts worse
|
Numerator 4 · Denominator 138 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.8 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.0
1.2 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
91.2%
3.4 pts better
|
93.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 92.3% · Q3 94.0% · Q4 98.0% · 4Q avg 94.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.5% |
95.0%
1.5 pts better
|
95.5%
1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.2%
2.2 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
9.6%
6.2 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.3% · Q3 2.3% · Q4 2.3% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
5.9%
3.4 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 14.7% · Q3 2.6% · Q4 4.9% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.5% |
20.7%
7.2 pts better
|
19.6%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 12.2% · Q3 10.3% · Q4 14.3% · 4Q avg 13.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
21.4%
18.3 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 3.2% · Q4 5.6% · 4Q avg 3.1% · 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 | 35.1% |
17.9%
17.2 pts worse
|
16.3%
18.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.1% |
16.2%
9.9 pts worse
|
14.9%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 33.3% · Q3 15.8% · Q4 22.5% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.1%
0.6 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.5%
1.5 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.1% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
16.1%
8.6 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 42.9% · Q3 24.3% · Q4 16.7% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
6.2%
3.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 1.0% · Q4 3.7% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
80.4%
9.3 pts better
|
81.7%
8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 89.2% · Q3 90.2% · Q4 85.6% · 4Q avg 89.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
12.2%
4.7 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.3% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
2.2%
1.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.4% |
78.2%
2.2 pts better
|
79.7%
0.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
24.2%
5.5 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 18.8% · Expected 24.0% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Nutrition and Dietary (7 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2025-03-17
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-17
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-17
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2025-03-17
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-03-17
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 2023-06-14
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-14
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-14
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-14
Inspection history
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-17
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-17
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 2025-03-17
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-04-15
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-04-15
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-15
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-04-15
Health
Keep all essential equipment working safely.
Corrected 2024-04-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-14
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-06-14
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-14
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-14
Health
Dispose of garbage and refuse properly.
Corrected 2023-06-14
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-14
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-06-14
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-14
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-14
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 2023-06-14
Penalties and ownership
Fine · fine $4,963
Fine
Fine · fine $5,315
Fine
Fine · fine $5,315
Fine
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
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5-star overall rating with 4-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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