Cycle 1
Health 2024-09-13 · Fire 2024-09-13
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Adel, GA
Southwell Health And Rehabilitation
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
260 Mj Taylor Road, Adel, GA
(229) 896-8077
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-09-01
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
1.29
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.86
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
4.27
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.79
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
1.35
CMS adjusted RN staffing hours
Adjusted total hours
4.49
CMS adjusted total nurse staffing hours
Case-mix index
1.30
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
6,075
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9881
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.55
Baseline 20.64% · Performance 20.25% · Measure score 2.55 · Achievement 2.55 · Improvement 0.60
Healthcare-associated infections
5.19
Baseline 8.91% · Performance 6.68% · Measure score 5.19 · Achievement 3.85 · Improvement 5.19
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
2.49
Baseline 2.66 hours · Performance 3.59 hours · Measure score 2.49 · Achievement 1.82 · Improvement 2.49
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.57% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 250 · Observed rate 9.6% · Lower 95% interval 7.87% |
| Discharge to community | 66.15% |
50.57%
15.6 pts better
|
Better than the National Rate · Eligible stays 241 · Observed rate 64.73% · Lower 95% interval 60.67% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 42.38% |
95.27%
52.9 pts worse
|
Numerator 89 · Denominator 210 |
| Falls with major injury | 0.95% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 210 |
| Discharge self-care score | 64.48% |
53.69%
10.8 pts better
|
Numerator 118 · Denominator 183 |
| Discharge mobility score | 60.66% |
50.94%
9.7 pts better
|
Numerator 111 · Denominator 183 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 210 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 4.57% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 6.67% |
8.2%
1.5 pts worse
|
Numerator 5 · Denominator 75 |
| Staff flu vaccination coverage | 75.56% |
42%
33.6 pts better
|
Numerator 102 · Denominator 135 |
| Discharge function score | 60.11% |
56.45%
3.7 pts better
|
Numerator 110 · Denominator 183 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.73% |
96.28%
2.5 pts better
|
Numerator 155 · Denominator 157 |
| Resident COVID-19 vaccinations up to date | 1.22% |
25.2%
24 pts worse
|
Numerator 1 · Denominator 82 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.2
0.5 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 1.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.0
1.5 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 0.7% |
3.2%
2.5 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
9.6%
8.9 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.4% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.9%
1.4 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 3.1% · Q3 4.7% · Q4 3.5% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
20.7%
8.1 pts better
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 13.4% · Q3 15.6% · Q4 10.2% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
21.4%
1 pts better
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 23.2% · Q3 21.2% · Q4 19.6% · 4Q avg 20.4% · 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 | 18.6% |
17.9%
0.7 pts worse
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 25.3% · Q3 20.2% · Q4 14.0% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
16.2%
6.8 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 6.8% · Q3 12.5% · Q4 9.4% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.1%
0.1 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 1.2% · Q4 1.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.5%
0.5 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.0% · Q3 0.0% · Q4 2.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.7% |
16.1%
3.4 pts better
|
19.8%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 13.2% · Q3 16.1% · Q4 9.3% · 4Q avg 12.7% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
6.2%
1.5 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 3.8% · Q3 3.8% · Q4 4.8% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
80.4%
19.3 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.3% · Q4 99.4% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
12.2%
8 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 3.9% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
2.2%
1.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
78.2%
19.6 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
24.2%
1.6 pts better
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 17.5% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-27 · Fire 2022-10-27
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2019-12-18 · Fire 2019-12-18
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-28
D · Potential for more than minimal harm
2022-10-27
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-11-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-13
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-09-13
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-13
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 2024-10-28
D · Potential for more than minimal harm
2024-09-13
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 2024-10-28
D · Potential for more than minimal harm
2024-09-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-13
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 2024-10-28
D · Potential for more than minimal harm
2024-09-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-13
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-10-28
E · Potential for more than minimal harm
2023-11-30
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 2024-01-14
D · Potential for more than minimal harm
2023-03-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-07
D · Potential for more than minimal harm
2023-03-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-07
D · Potential for more than minimal harm
2023-03-23
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 2023-05-07
D · Potential for more than minimal harm
2023-03-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-07
E · Potential for more than minimal harm
2022-10-27
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 2022-12-11
E · Potential for more than minimal harm
2022-10-27
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 2022-12-11
D · Potential for more than minimal harm
2022-10-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-11
F · Potential for more than minimal harm
2019-12-18
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2020-02-01
Penalties and ownership
What sits behind the stars
Ownership
Tift Regional Health System Inc
5% Or Greater Direct Ownership Interest · Organization
Brooks, Troy
Corporate Officer · Individual
Dorman, Christopher
5% Or Greater Direct Ownership Interest · Individual
Dorman, Christopher
Corporate Officer · Individual
Fausett, Thomas
Corporate Officer · Individual
Kimball, Mark
Operational/Managerial Control · Individual
Kimball, Mark
Corporate Officer · Individual
Lawal, John
Corporate Officer · Individual
Tift Regional Health System Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Berrien Oaks Nursing And Rehab Center
Nashville, GA
1-star overall rating with 3-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Pruitthealth - Lakehaven, LLC
Valdosta, GA
1-star overall rating with 1-star inspections with $68,297 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Valdosta, LLC
Valdosta, GA
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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