Cycle 1
Health 2025-09-14 · Fire 2025-09-14
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Augusta, GA
Stevens Park Health And Rehabilitation
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
820 Stevens Creek Road, Augusta, GA
(706) 737-0350
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
39
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
2009-10-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
48 facilities
Chain averages 4 overall / 4 health / 3 staffing / 3 quality stars
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
0.92
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
4.27
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,220
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9878
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
0
Baseline 6.09% · Performance 8.61% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.41
Baseline 61.11% · Performance 37.50% · Measure score 6.41 · Achievement 6.41 · Improvement 6.01
Adjusted total nurse staffing
3.68
Baseline 3.84 hours · Performance 4.12 hours · Measure score 3.68 · Achievement 3.68 · Improvement 0.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.49% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 18.64% · Lower 95% interval 8.98% |
| Discharge to community | 45.05% |
50.57%
5.5 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 41.38% · Lower 95% interval 33.24% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 76.19% |
95.27%
19.1 pts worse
|
Numerator 32 · Denominator 42 |
| Falls with major injury | 2.38% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 42 |
| Discharge self-care score | 51.52% |
53.69%
2.2 pts worse
|
Numerator 17 · Denominator 33 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 11 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 2 · Denominator 42 · Adjusted rate 4.72% |
| Healthcare-associated infections requiring hospitalization | 8.61% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 12.9% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 63 |
| Staff flu vaccination coverage | 38.24% |
42%
3.8 pts worse
|
Numerator 26 · Denominator 68 |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 17 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · 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 | 53.57% |
25.2%
28.4 pts better
|
Numerator 15 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
91.2%
6.7 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 97.1% · Q3 100.0% · Q4 97.2% · 4Q avg 97.9% |
| 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 | 2.1% |
3.2%
1.1 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.0% · Q4 2.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
9.6%
8 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 3.1% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
5.9%
3.1 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.8% · Q3 0.0% · Q4 3.8% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
20.7%
1.1 pts better
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 17.9% · Q3 20.0% · Q4 18.5% · 4Q avg 19.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
21.4%
10.5 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 8.3% · Q3 8.0% · Q4 14.8% · 4Q avg 10.9% · 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 | 21.8% |
17.9%
3.9 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.4% |
16.2%
16.2 pts worse
|
14.9%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 35.7% · Q3 20.8% · Q4 40.0% · 4Q avg 32.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.1%
0.5 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.4% · Q3 1.8% · Q4 1.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
2.5%
1.2 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 3.0% · Q4 8.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.8% |
16.1%
3.7 pts worse
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 18.7% · Q3 18.7% · Q4 27.4% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
6.2%
5.1 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 8.4% · Q3 11.4% · Q4 10.0% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.7% |
80.4%
1.3 pts better
|
81.7%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 76.5% · Q3 83.3% · Q4 89.3% · 4Q avg 81.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
12.2%
3.9 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 6.9% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
2.2%
1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.4% |
78.2%
1.2 pts better
|
79.7%
0.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 8.4% |
24.2%
15.8 pts better
|
23.9%
15.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 6.9% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-18 · Fire 2024-02-18
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-06-19 · Fire 2022-06-19
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-09-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-09-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-24
D · Potential for more than minimal harm
2024-02-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-14
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 2025-10-24
D · Potential for more than minimal harm
2025-09-14
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 2025-10-24
F · Potential for more than minimal harm
2022-06-19
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 2022-08-03
Penalties and ownership
What sits behind the stars
Ownership
Cable, Paul
Corporate Director · Individual
Clinical Services Inc
Operational/Managerial Control · Organization
Community Health Systems Inc
5% Or Greater Direct Ownership Interest · Organization
Dennis, Kathryn
Corporate Director · Individual
Health Scholarships Inc
5% Or Greater Direct Ownership Interest · Organization
Hodges, Kimberly
Operational/Managerial Control · Individual
Lane, Tina
Operational/Managerial Control · Individual
Moody, Teresa
Corporate Officer · Individual
Nichols, Joseph
Corporate Director · Individual
Rollins, Ronnie
Corporate Director · Individual
Shiers, Ashleigh
Operational/Managerial Control · Individual
Stevens Park Health And Rehabilitation Center LLC
5% Or Greater Mortgage Interest · Organization
Wall, Joseph
Corporate Director · Individual
Warnock, Ralph
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Place At Martinez, The
Augusta, GA
1-star overall rating with 2-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Harrington Park Health And Rehabilitation
Augusta, GA
3-star overall rating with 2-star inspections with $168,457 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Harborview Health Center Of Augusta
Augusta, GA
1-star overall rating with 2-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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