Cycle 1
Health 2024-11-10 · Fire 2024-11-10
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Columbus, GA
Spring Harbor At Green Island
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
200 Spring Harbor Drive, Columbus, GA
(706) 576-6027
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
40
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-10-06
CMS approved date
Coverage
Medicare
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
0.84
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
3.76
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
5.89
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
2.13
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
5.55
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
6.10
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
73%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,362
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0041
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
0
Baseline 40.00% · Performance 76.92% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
10
Performance 6.08 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.71% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 45 · Observed rate 11.11% · Lower 95% interval 7.12% |
| Discharge to community | 34.35% |
50.57%
16.2 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 22.86% · Lower 95% interval 23.72% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 23 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 35 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 1.7 |
2.2
0.5 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.0
0.4 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.8% |
91.2%
20.4 pts worse
|
93.4%
22.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.7% · Q2 71.0% · Q3 70.0% · Q4 65.5% · 4Q avg 70.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.4% |
95.0%
3.6 pts worse
|
95.5%
4.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.2%
0.1 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 3.3% · Q4 3.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
9.6%
8.7 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
5.9%
3.5 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.4% |
20.7%
10.7 pts worse
|
19.6%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 25.9% · 4Q avg 31.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
21.4%
11.4 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · 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 | 17.0% |
17.9%
0.9 pts better
|
16.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
16.2%
3.2 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 12.5% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.5%
0.9 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 10.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
16.1%
9.9 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 22.6% · Q3 30.6% · Q4 29.5% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
6.2%
5.7 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.3% |
80.4%
31.1 pts worse
|
81.7%
32.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 60.9% · 4Q avg 49.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.5% |
12.2%
3.3 pts worse
|
12.0%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 13.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
2.2%
0.4 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.1% |
24.2%
6.1 pts better
|
23.9%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 18.2% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-04 · Fire 2023-06-04
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-02 · Fire 2021-12-02
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 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
2024-11-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-10
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 2024-12-25
E · Potential for more than minimal harm
2024-11-10
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 2024-12-25
D · Potential for more than minimal harm
2024-11-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-25
E · Potential for more than minimal harm
2023-06-04
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-04
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-19
D · Potential for more than minimal harm
2021-12-02
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 2022-01-14
D · Potential for more than minimal harm
2021-12-02
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 2022-01-14
D · Potential for more than minimal harm
2021-12-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-14
Penalties and ownership
What sits behind the stars
Ownership
Campbell, Michael
Operational/Managerial Control · Individual
Drew, Laura
Corporate Officer · Individual
Peters, Janet
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Orchard View Rehabilitation & Skilled Nursing Ctr
Columbus, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Ridgecrest Rehab & Skilled Nursing Center
Columbus, GA
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#3
Magnolia Manor Of Columbus Nursing Center - East
Columbus, GA
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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