Cycle 1
Health 2025-11-21 · Fire 2025-11-21
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lagrange, GA
Peachtree Nursing And Rehabilitation LLC
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
200 Medical Drive, Lagrange, GA
(706) 845-3256
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-10-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.50
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.46
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
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.83
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
411
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
70.50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0226
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.08
Baseline 18.82% · Performance 17.22% · Measure score 9.08 · Achievement 9.08 · Improvement 8.42
Healthcare-associated infections
5.80
Baseline 5.19% · Performance 6.10% · Measure score 5.80 · Achievement 5.80 · Improvement 0
Total nurse turnover
9.40
Baseline 18.75% · Performance 25.25% · Measure score 9.40 · Achievement 9.40 · Improvement 0
Adjusted total nurse staffing
3.92
Baseline 4.49 hours · Performance 4.19 hours · Measure score 3.92 · Achievement 3.92 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 230 · Observed rate 10.87% · Lower 95% interval 8.31% |
| Discharge to community | 52.53% |
50.57%
2 pts better
|
No Different than the National Rate · Eligible stays 193 · Observed rate 47.15% · Lower 95% interval 46.33% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.21% |
95.27%
3.9 pts better
|
Numerator 126 · Denominator 127 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 1 · Denominator 127 |
| Discharge self-care score | 54.17% |
53.69%
0.5 pts better
|
Numerator 52 · Denominator 96 |
| Discharge mobility score | 58.33% |
50.94%
7.4 pts better
|
Numerator 56 · Denominator 96 |
| Pressure ulcers or injuries, new or worsened | 1.57% |
2.29%
0.7 pts better
|
Numerator 2 · Denominator 127 · Adjusted rate 1.33% |
| Healthcare-associated infections requiring hospitalization | 6.1% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 3.81% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 140 |
| Staff flu vaccination coverage | 79.7% |
42%
37.7 pts better
|
Numerator 106 · Denominator 133 |
| Discharge function score | 63.54% |
56.45%
7.1 pts better
|
Numerator 61 · Denominator 96 |
| Transfer of health information to provider | 98.39% |
95.95%
2.4 pts better
|
Numerator 61 · Denominator 62 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 70.18% |
25.2%
45 pts better
|
Numerator 40 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.2
About the same
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.9 · 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 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
91.2%
4.6 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 96.0% · Q3 97.0% · Q4 94.4% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
95.0%
0.3 pts better
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.2%
1.2 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.0% · Q3 2.0% · Q4 0.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
9.6%
2.8 pts better
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 4.3% · Q3 9.5% · Q4 12.0% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.9%
0.5 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 5.6% · Q3 3.3% · Q4 7.4% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.2% |
20.7%
7.5 pts worse
|
19.6%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 27.7% · Q3 32.3% · Q4 28.4% · 4Q avg 28.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.0% |
21.4%
4.6 pts worse
|
16.7%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 24.4% · Q3 29.1% · Q4 25.9% · 4Q avg 26.0% · 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 | 7.6% |
17.9%
10.3 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 10.7% · Q3 2.3% · Q4 13.4% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
16.2%
2.3 pts better
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 21.8% · Q3 9.1% · Q4 10.8% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
1.1%
1.9 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 3.0% · Q3 1.5% · Q4 2.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.5%
1.2 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.1% |
16.1%
About the same
|
19.8%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 21.1% · Q3 14.0% · Q4 18.7% · 4Q avg 16.1% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
6.2%
2.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.8% · Q3 3.6% · Q4 3.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
80.4%
1.2 pts better
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 80.7% · Q3 77.9% · Q4 80.6% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
12.2%
0.1 pts better
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 11.2% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.2%
0.6 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.5% |
78.2%
19.7 pts worse
|
79.7%
21.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.0% |
24.2%
3.2 pts better
|
23.9%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 20.1% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-25 · Fire 2024-07-25
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-15 · Fire 2022-12-15
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-11-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-11-21
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-11-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-11-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-21
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 2025-12-22
D · Potential for more than minimal harm
2025-11-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-11-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-11-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-12-22
F · Potential for more than minimal harm
2024-07-25
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 2024-09-06
D · Potential for more than minimal harm
2024-07-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-07-25
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 2024-09-06
D · Potential for more than minimal harm
2022-12-15
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 2023-01-28
Penalties and ownership
What sits behind the stars
Ownership
Wellstar Health System Inc
5% Or Greater Indirect Ownership Interest · Organization
West Georgia Medical Center, Inc
5% Or Greater Direct Ownership Interest · Organization
Aziz, Arif
Corporate Director · Individual
Beckford, Avril
Corporate Director · Individual
Brock, William
Corporate Director · Individual
Brumby, Otis
Corporate Director · Individual
Budzinski, Anthony
W-2 Managing Employee · Individual
Burdette, Hiram
Corporate Director · Individual
Cunningham, James
Corporate Director · Individual
Douglass, Paul
Corporate Director · Individual
Erzuah, Ebenezer
W-2 Managing Employee · Individual
Holmes, James
Corporate Director · Individual
Hornsby, James
Corporate Director · Individual
Johnson, Terrell
Corporate Director · Individual
Mckibben, John
Corporate Director · Individual
Miller, Gary
Corporate Director · Individual
Moore, Mitzi
Corporate Director · Individual
Morgan, Greg
Corporate Director · Individual
Richardson, Edward
Corporate Director · Individual
Ros, Frank
Corporate Director · Individual
Saunders, Candice
Corporate Officer · Individual
Saunders, Candice
W-2 Managing Employee · Individual
Swayze, Orrin
Corporate Director · Individual
Yadav, Ambica
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Lagrange Care Center LLC
Lagrange, GA
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Green Acres Care Center LLC
Lagrange, GA
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Diversicare Of Lanett
Lanett, AL
4-star overall rating with 4-star inspections with 9 fire-safety deficiencies in the latest cycle
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