Cycle 1
Health 2024-11-21 · Fire 2024-11-21
6 health deficiencies
Top issue: Resident Rights (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Thomson, GA
Thomson Health And Rehabilitation
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
511 Mt. Pleasant Road, Thomson, GA
(706) 595-5574
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peach Health Group
Operator or chain grouping
Approved since
1989-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 2 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
0.28
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,715
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.33% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.76
Baseline 7.16% · Performance 7.31% · Measure score 1.76 · Achievement 1.76 · Improvement 0
Total nurse turnover
3.09
Performance 51.04% · Measure score 3.09 · Achievement 3.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.40
Baseline 3.75 hours · Performance 3.48 hours · Measure score 1.40 · Achievement 1.40 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.61% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 17.24% · Lower 95% interval 7.25% |
| Discharge to community | 44.58% |
50.57%
6 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 35.71% · Lower 95% interval 30.56% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 5 · Denominator 20 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 5 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 6.67% |
2.29%
4.4 pts worse
|
Numerator 2 · Denominator 30 · Adjusted rate 4.9% |
| Healthcare-associated infections requiring hospitalization | 7.31% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 9.3% · Lower 95% interval 4.54% |
| Staff COVID-19 vaccination coverage | 2.59% |
8.2%
5.6 pts worse
|
Numerator 3 · Denominator 116 |
| Staff flu vaccination coverage | 18.07% |
42%
23.9 pts worse
|
Numerator 30 · Denominator 166 |
| Discharge function score | 40% |
56.45%
16.5 pts worse
|
Numerator 8 · Denominator 20 |
| 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 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15% |
25.2%
10.2 pts worse
|
Numerator 3 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 65.8% |
91.2%
25.4 pts worse
|
93.4%
27.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.4% · Q2 66.7% · Q3 65.0% · Q4 64.4% · 4Q avg 65.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.5% |
95.0%
7.5 pts worse
|
95.5%
8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.2%
0.9 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.0% · Q3 2.9% · Q4 1.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 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 who lose too much weight | 3.3% |
5.9%
2.6 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.8% · Q3 2.2% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
20.7%
6.7 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.1% · Q3 15.1% · Q4 14.8% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
21.4%
8.7 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 11.1% · Q3 18.5% · Q4 9.5% · 4Q avg 12.7% · 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 | 15.5% |
17.9%
2.4 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 17.9% · Q3 14.5% · Q4 13.0% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
16.2%
1.2 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 13.4% · Q3 16.7% · Q4 27.2% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.1%
0.2 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.7% · Q3 0.7% · Q4 1.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.5%
2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
16.1%
4.8 pts worse
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 23.0% · Q3 20.4% · Q4 19.7% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
6.2%
0.6 pts better
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 5.0% · Q3 4.3% · Q4 5.6% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.2% |
80.4%
33.2 pts worse
|
81.7%
34.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.0% · Q2 61.0% · Q3 46.3% · Q4 26.4% · 4Q avg 47.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
12.2%
4.8 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.3% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.2%
0.7 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.2% |
78.2%
27 pts worse
|
79.7%
28.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.6% |
24.2%
10.6 pts better
|
23.9%
10.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 16.7% · Expected 29.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-15 · Fire 2023-06-15
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2021-10-28 · Fire 2021-10-28
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
E · Potential for more than minimal harm
2024-11-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-05
E · Potential for more than minimal harm
2024-11-21
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-05
F · Potential for more than minimal harm
2023-06-15
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-30
F · Potential for more than minimal harm
2023-06-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-30
D · Potential for more than minimal harm
2023-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-30
D · Potential for more than minimal harm
2023-06-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-21
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 2025-01-05
E · Potential for more than minimal harm
2024-11-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-05
E · Potential for more than minimal harm
2024-11-21
F625 · Resident Rights Deficiencies
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 2025-01-05
D · Potential for more than minimal harm
2024-11-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
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 2025-01-05
E · Potential for more than minimal harm
2023-06-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-30
D · Potential for more than minimal harm
2023-06-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-30
D · Potential for more than minimal harm
2023-06-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-30
D · Potential for more than minimal harm
2023-06-15
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 2023-07-30
D · Potential for more than minimal harm
2023-06-15
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 2023-07-30
D · Potential for more than minimal harm
2023-06-15
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-07-30
D · Potential for more than minimal harm
2021-10-28
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 2021-12-12
D · Potential for more than minimal harm
2021-10-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-12
B · Minimal harm
2021-10-28
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 2021-12-12
Penalties and ownership
What sits behind the stars
Ownership
Forrister, Karen
Operational/Managerial Control · Individual
Lemcke, David
Operational/Managerial Control · Individual
Newsome, Lorie
Operational/Managerial Control · Individual
Peach Health Group LLC
Operational/Managerial Control · Organization
Powell, Michael
Operational/Managerial Control · Individual
Rhine Investment Group Llp
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
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Warrenton Woods of Journey LLC
Warrenton, GA
2-star overall rating with 1-star inspections with 8 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Gibson Health Opco LLC
Gibson, GA
5-star overall rating with 5-star inspections with $14,732 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Lake Crossing Health Center Pac LLC
Appling, GA
1-star overall rating with 2-star inspections with $19,321 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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