Cycle 1
Health 2025-02-20 · Fire 2025-02-20
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Evans, GA
Pavilion At Brandon Wilde
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4275 Owens Road, Evans, GA
(706) 868-9800
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Services
Operator or chain grouping
Approved since
1992-06-17
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 4 health / 4 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
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.60
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.99
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.77
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
4.97
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,827
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.95
Baseline 19.76% · Performance 20.06% · Measure score 2.95 · Achievement 2.95 · Improvement 0
Healthcare-associated infections
0
Baseline 6.23% · Performance 8.59% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
7.52
Baseline 5.75 hours · Performance 5.22 hours · Measure score 7.52 · Achievement 7.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.47% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 8.04% · Lower 95% interval 6.95% |
| Discharge to community | 55.75% |
50.57%
5.2 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 52.04% · Lower 95% interval 46.77% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.36% |
95.27%
1.1 pts better
|
Numerator 53 · Denominator 55 |
| Falls with major injury | 7.27% |
0.77%
6.5 pts worse
|
Numerator 4 · Denominator 55 |
| Discharge self-care score | 52.5% |
53.69%
1.2 pts worse
|
Numerator 21 · Denominator 40 |
| Discharge mobility score | 37.5% |
50.94%
13.4 pts worse
|
Numerator 15 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 55 · Adjusted rate 3.22% |
| Healthcare-associated infections requiring hospitalization | 8.59% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 9.52% · Lower 95% interval 4.49% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 70.51% |
42%
28.5 pts better
|
Numerator 55 · Denominator 78 |
| Discharge function score | 45% |
56.45%
11.5 pts worse
|
Numerator 18 · Denominator 40 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 71.88% |
25.2%
46.7 pts better
|
Numerator 23 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.2
0.7 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.4 · Expected 1.6 · 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 1.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
91.2%
7.9 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.1% · Q3 98.1% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
95.0%
3.4 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| 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 6.8% · Q2 3.8% · Q3 7.7% · Q4 5.4% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
9.6%
9.1 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.9%
1.6 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.0% · Q3 5.9% · Q4 2.7% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.2% |
20.7%
4.5 pts better
|
19.6%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 18.2% · Q3 17.6% · Q4 15.4% · 4Q avg 16.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
21.4%
10.4 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 8.0% · Q3 4.0% · Q4 7.1% · 4Q avg 11.0% · 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 | 18.7% |
17.9%
0.8 pts worse
|
16.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
16.2%
3.8 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 16.7% · Q3 25.0% · Q4 5.9% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.1%
0.5 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.4% · Q3 1.5% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
2.5%
1.7 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 5.8% · Q3 1.9% · Q4 7.4% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
16.1%
8.8 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 29.5% · Q3 16.4% · Q4 21.2% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
6.2%
3.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.3% · Q3 1.7% · Q4 1.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
80.4%
17.6 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.4% · Q3 97.7% · Q4 97.1% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
12.2%
2 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.5% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
2.2%
1.2 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 4.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.5% |
78.2%
19.3 pts better
|
79.7%
17.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
24.2%
1.2 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 23.8% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-17 · Fire 2023-09-17
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-01-27 · Fire 2022-01-27
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
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
2025-02-20
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-02-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-02-20
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-06
E · Potential for more than minimal harm
2023-09-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-17
K222 · Egress Deficiencies
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 2023-11-01
D · Potential for more than minimal harm
2023-09-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-02-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-02-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-02-20
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 2025-04-06
D · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-06
D · Potential for more than minimal harm
2023-11-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-09-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-17
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 2023-11-01
D · Potential for more than minimal harm
2023-09-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-17
F758 · Pharmacy Service Deficiencies
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 2023-11-01
D · Potential for more than minimal harm
2023-09-17
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-11-01
G · Actual harm
2022-01-27
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 2022-02-18
G · Actual harm
2022-01-27
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 2022-02-18
Penalties and ownership
What sits behind the stars
Ownership
Bank Of America Corp
5% Or Greater Security Interest · Organization
Bank Of America Corp
5% Or Greater Mortgage Interest · Organization
Bird, John
Operational/Managerial Control · Individual
Bird, John
Corporate Officer · Individual
Lahey, Daniel
Corporate Officer · Individual
Legendary, Zechariah
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Merrill, Frederick
Operational/Managerial Control · Individual
Pulliam, John
Operational/Managerial Control · Individual
Shaw, Gelynna
Operational/Managerial Control · Individual
Shaw, Gelynna
Corporate Officer · Individual
Uhlemann, Bridgette
Operational/Managerial Control · Individual
Victor, Jason
Operational/Managerial Control · Individual
Victor, Jason
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Pruitthealth - Evans, LLC
Evans, GA
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Harrington Park Health And Rehabilitation
Augusta, GA
3-star overall rating with 2-star inspections with $168,457 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Harborview Health Center Of Augusta
Augusta, GA
1-star overall rating with 2-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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