Cycle 1
Health 2025-11-21 · Fire 2025-11-21
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Saint Marys, GA
Senior Care Center - St Marys
2-star overall rating with 3-star inspections with $4,072 in total fines with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
805 Dilworth Street, Saint Marys, GA
(912) 882-4281
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-03-20
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
0.57
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.60
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
2.87
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.31
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
2.88
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,449
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9896
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.30
Baseline 20.13% · Performance 17.12% · Measure score 9.30 · Achievement 9.30 · Improvement 9
Healthcare-associated infections
4.21
Baseline 7.61% · Performance 6.58% · Measure score 4.21 · Achievement 4.21 · Improvement 3.45
Total nurse turnover
0
Performance 73.77% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.96
Baseline 4.43 hours · Performance 3.35 hours · Measure score 0.96 · Achievement 0.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.31% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 10.81% · Lower 95% interval 7.36% |
| Discharge to community | 52.52% |
50.57%
2 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 44.44% · Lower 95% interval 39.92% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 89.58% |
95.27%
5.7 pts worse
|
Numerator 43 · Denominator 48 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 2 · Denominator 48 |
| Discharge self-care score | 56.76% |
53.69%
3.1 pts better
|
Numerator 21 · Denominator 37 |
| Discharge mobility score | 48.65% |
50.94%
2.3 pts worse
|
Numerator 18 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 48 · Adjusted rate 2.25% |
| Healthcare-associated infections requiring hospitalization | 6.58% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 5.13% · Lower 95% interval 3.51% |
| 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 | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 59.46% |
56.45%
3 pts better
|
Numerator 22 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 16 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.4% |
91.2%
1.8 pts worse
|
93.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 82.5% · Q3 93.1% · Q4 96.4% · 4Q avg 89.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.2%
0.8 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.3% · Q3 3.4% · Q4 3.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
9.6%
8.1 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 2.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 11.4% |
5.9%
5.5 pts worse
|
5.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.5% · Q3 21.3% · Q4 13.6% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
20.7%
0.8 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 27.1% · Q3 20.4% · Q4 13.0% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
21.4%
8.2 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 8.3% · Q3 14.6% · Q4 17.5% · 4Q avg 13.2% · 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 | 38.1% |
17.9%
20.2 pts worse
|
16.3%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 51.1% · 4Q avg 38.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 38.9% |
16.2%
22.7 pts worse
|
14.9%
24 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 42.6% · Q3 40.4% · Q4 37.8% · 4Q avg 38.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.1%
0.4 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.5%
0.2 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.6% · Q3 1.8% · Q4 1.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.2% |
16.1%
15.1 pts worse
|
19.8%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 36.6% · Q3 25.4% · Q4 30.1% · 4Q avg 31.2% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.2%
0.9 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.4% · Q3 3.0% · Q4 2.5% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.6% |
80.4%
4.8 pts worse
|
81.7%
6.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 57.5% · Q2 75.8% · Q3 81.1% · Q4 83.3% · 4Q avg 75.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
12.2%
3.1 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.3% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.0% |
78.2%
12.8 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.6% |
24.2%
12.6 pts better
|
23.9%
12.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.6% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-06-30 · Fire 2022-06-30
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Not marked corrected
F · 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.
Not marked corrected
F · Potential for more than minimal harm
2025-11-21
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Not marked corrected
D · Potential for more than minimal harm
2025-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
D · Potential for more than minimal harm
2025-11-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Not marked corrected
D · Potential for more than minimal harm
2024-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-28
D · Potential for more than minimal harm
2022-06-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-21
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 2025-12-30
D · Potential for more than minimal harm
2025-11-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-12-30
F · Potential for more than minimal harm
2024-03-14
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 2024-04-28
F · Potential for more than minimal harm
2024-03-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-28
F · Potential for more than minimal harm
2024-03-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-14
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-14
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 2024-04-28
D · Potential for more than minimal harm
2024-03-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-21
F · Potential for more than minimal harm
2022-06-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-12
F · Potential for more than minimal harm
2022-06-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-30
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 2022-08-12
Penalties and ownership
What sits behind the stars
$4,072
2024-03-14
Fine
Fine · fine $4,072
Fine
Ownership
Barker, Jeffery
Corporate Director · Individual
Chitty, Stephen
Corporate Director · Individual
Grant, Rhondia
W-2 Managing Employee · Individual
Hampton, Kay
Corporate Director · Individual
Hepburn, Valerie
Corporate Director · Individual
Hodges, Michael
Corporate Director · Individual
Hughes, J
Corporate Director · Individual
Jones, Mitchell
Corporate Director · Individual
Millzaao, John
Operational/Managerial Control · Individual
Millzaao, John
Corporate Officer · Individual
Scherneck, Michael
Operational/Managerial Control · Individual
Scherneck, Michael
Corporate Officer · Individual
Southeast Georgia Health System, Inc
Operational/Managerial Control · Organization
Turner, Robert
Corporate Director · Individual
Willis, Gary
Corporate Director · Individual
Wilson, Shirley
Corporate Director · Individual
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