8 health deficiencies
Top issue: Infection Control (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Reidsville, GA
1-star overall rating with 2-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
142 Memorial Drive, Reidsville, GA
(912) 557-4345
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
92
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Beacon Health Management
Operator or chain grouping
Approved since
1994-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 1 overall / 2 health / 2 staffing / 2 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
RN hours / resident day
0.22
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
1.62
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
2.86
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.59
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
2.61
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
5,867
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.70
Performance 19.72% · Measure score 3.70 · Achievement 3.70 · This facility did not have sufficient data to calculate a baseline period measure result.
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
6.73
Baseline 39.13% · Performance 36.17% · Measure score 6.73 · Achievement 6.73 · Improvement 1.57
Adjusted total nurse staffing
0
Baseline 3.56 hours · Performance 3.22 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.11% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 6% · Lower 95% interval 6.01% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 90% |
95.27%
5.3 pts worse
|
Numerator 27 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| 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 | 6.67% |
2.29%
4.4 pts worse
|
Numerator 2 · Denominator 30 · Adjusted rate 5.57% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 90% |
8.2%
81.8 pts better
|
Numerator 72 · Denominator 80 |
| Staff flu vaccination coverage | 12.66% |
42%
29.3 pts worse
|
Numerator 10 · Denominator 79 |
| 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 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
2.2
1.6 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 13.3% |
91.2%
77.9 pts worse
|
93.4%
80.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 12.3% · Q3 16.7% · Q4 15.7% · 4Q avg 13.3% |
| 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 | 5.3% |
3.2%
2.1 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.5% · Q3 5.6% · Q4 4.3% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.5% |
9.6%
3.9 pts worse
|
11.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 11.8% · Q4 43.9% · 4Q avg 13.5% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.9%
0.5 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.8% · Q3 1.6% · Q4 8.8% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 44.0% |
20.7%
23.3 pts worse
|
19.6%
24.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.0% · Q2 42.9% · Q3 45.9% · Q4 42.4% · 4Q avg 44.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 40.5% |
21.4%
19.1 pts worse
|
16.7%
23.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 40.0% · Q3 37.0% · Q4 42.3% · 4Q avg 40.5% · 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 | 33.8% |
17.9%
15.9 pts worse
|
16.3%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.9% · Q2 33.9% · Q3 11.4% · Q4 47.6% · 4Q avg 33.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 39.7% |
16.2%
23.5 pts worse
|
14.9%
24.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.3% · Q2 30.2% · Q3 48.3% · Q4 37.3% · 4Q avg 39.7% · 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 | 1.4% |
2.5%
1.1 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 1.4% · Q4 1.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.9% |
16.1%
1.2 pts better
|
19.8%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 17.1% · Q3 8.8% · Q4 10.7% · 4Q avg 14.9% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.2%
0.8 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.7% · Q3 2.9% · Q4 4.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.9% |
80.4%
23.5 pts worse
|
81.7%
24.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 57.4% · Q3 60.0% · Q4 62.5% · 4Q avg 56.9% |
| 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 · 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 | 100.0% |
78.2%
21.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Top issue: Infection Control (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-03
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-10
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-10
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-11
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-11
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-11
Inspection history
Health
Implement a program that monitors antibiotic use.
Corrected 2025-11-20
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-11-20
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-11-20
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-11-20
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-11-20
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-11-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-10
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-10
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-10
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-05-10
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 2024-05-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-10
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-29
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-21
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-11
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-08-11
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-08-11
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-08-11
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-08-11
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-11
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 2022-08-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-08-11
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-08-11
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
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