Cycle 1
Health 2025-03-03 · Fire 2025-03-03
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Monticello, GA
Retreat, The
3-star overall rating with 3-star inspections with $15,269 in total fines with 4 recent health deficiencies
898 College St, Monticello, GA
(706) 468-8826
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-08-06
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,560
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.04
Baseline 42.22% · Performance 55.36% · Measure score 2.04 · Achievement 2.04 · Improvement 0
Adjusted total nurse staffing
5.86
Baseline 4.89 hours · Performance 4.74 hours · Measure score 5.86 · Achievement 5.86 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 3 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.94% |
8.2%
1.3 pts worse
|
Numerator 5 · Denominator 72 |
| Staff flu vaccination coverage | 74.6% |
42%
32.6 pts better
|
Numerator 47 · Denominator 63 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.2
1.2 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.6 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.0
1.5 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 2.3 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
91.2%
7.3 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 97.9% · Q3 100.0% · Q4 98.1% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
95.0%
1.1 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.2%
0.2 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 2.0% · Q4 1.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 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 who lose too much weight | 4.4% |
5.9%
1.5 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.2% · Q3 2.3% · Q4 8.5% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.5% |
20.7%
2.8 pts worse
|
19.6%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 26.1% · Q3 22.7% · Q4 23.4% · 4Q avg 23.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.4% |
21.4%
3 pts worse
|
16.7%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 18.9% · Q3 27.0% · Q4 23.3% · 4Q avg 24.4% · 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 | 12.0% |
17.9%
5.9 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 9.4% · Q3 10.9% · Q4 6.4% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
16.2%
3.5 pts better
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 12.2% · Q3 12.8% · Q4 14.0% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
1.1%
1.4 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.1% · Q3 1.8% · Q4 1.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.5% |
2.5%
7 pts worse
|
1.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 8.3% · Q3 8.0% · Q4 5.6% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
16.1%
3.2 pts worse
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 19.5% · Q3 18.4% · Q4 14.2% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
6.2%
3.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 1.7% · Q4 4.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
80.4%
12.9 pts better
|
81.7%
11.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 93.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-12 · Fire 2023-11-12
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.
Cycle 3
Health 2022-05-08 · Fire 2022-05-08
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-03
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 2025-04-17
D · Potential for more than minimal harm
2025-03-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-17
D · Potential for more than minimal harm
2025-03-03
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 2025-04-17
D · Potential for more than minimal harm
2025-03-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-17
D · Potential for more than minimal harm
2023-11-12
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 2023-12-27
J · Immediate jeopardy
2023-05-26
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-05-23
D · Potential for more than minimal harm
2022-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-22
Penalties and ownership
What sits behind the stars
$15,269
2023-05-26
Fine
Fine · fine $15,269
Fine
Ownership
Abney, Stuart
W-2 Managing Employee · Individual
Cumbie, Robert
Corporate Director · Individual
Cumbie, Robert
Corporate Officer · Individual
Gordon, Angela
Corporate Director · Individual
Hildebrant, Alison
Corporate Director · Individual
Hudgins, Laura
W-2 Managing Employee · Individual
Jasper Health Services Inc.
5% Or Greater Direct Ownership Interest · Organization
Johnston, Lyndsy
Corporate Director · Individual
Jordan, Steven
Corporate Director · Individual
Lane, Derrick
W-2 Managing Employee · Individual
Leach, David
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Westbury Center Of Jackson For Nursing And Healing
Jackson, GA
2-star overall rating with 3-star inspections with $8,512 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Pruitthealth - Monroe
Forsyth, GA
4-star overall rating with 4-star inspections
#3
Eatonton Health And Rehabilitation
Eatonton, GA
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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