Cycle 1
Health 2025-03-28 · Fire 2025-03-28
2 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Alma, GA
Twin Oaks Convalescent Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
301 S0uth Baker Street, Alma, GA
(912) 632-7293
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-01-01
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
0.63
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.30
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,142
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.39% · Performance 22.84% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.36
Baseline 7.43% · Performance 7.43% · Measure score 1.36 · Achievement 1.36 · Improvement 0
Total nurse turnover
3.22
Baseline 57.14% · Performance 50.51% · Measure score 3.22 · Achievement 3.22 · Improvement 1.56
Adjusted total nurse staffing
3.95
Baseline 3.73 hours · Performance 4.20 hours · Measure score 3.95 · Achievement 3.95 · Improvement 1.81
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.38% |
10.72%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 19.48% · Lower 95% interval 9.86% |
| Discharge to community | 50.12% |
50.57%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 46.3% · Lower 95% interval 39.44% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 56.76% |
53.69%
3.1 pts better
|
Numerator 21 · Denominator 37 |
| Discharge mobility score | 40.54% |
50.94%
10.4 pts worse
|
Numerator 15 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 1.56% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 64 · Adjusted rate 1.42% |
| Healthcare-associated infections requiring hospitalization | 7.43% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 7.27% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 0.5% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 201 |
| Staff flu vaccination coverage | 23.62% |
42%
18.4 pts worse
|
Numerator 60 · Denominator 254 |
| Discharge function score | 45.95% |
56.45%
10.5 pts worse
|
Numerator 17 · Denominator 37 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| 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 | 21.05% |
25.2%
4.1 pts worse
|
Numerator 8 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.2 |
2.0
3.2 pts worse
|
1.8
3.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.2 · Observed 5.0 · Expected 1.6 · 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 | 4.5% |
3.2%
1.3 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.0% · Q3 1.5% · Q4 2.9% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
9.6%
4.3 pts better
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 2.0% · Q3 8.2% · Q4 5.3% · 4Q avg 5.3% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
5.9%
0.4 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.1% · Q3 3.5% · Q4 10.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
20.7%
1.3 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 17.7% · Q3 20.0% · Q4 12.5% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
21.4%
9.5 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 15.4% · Q3 9.3% · Q4 11.9% · 4Q avg 11.9% · 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 | 19.4% |
17.9%
1.5 pts worse
|
16.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
16.2%
0.9 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 19.2% · Q3 15.7% · Q4 9.8% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.1%
0.3 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.9% · Q4 0.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.5%
1 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.6% · Q3 3.2% · Q4 4.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.4% |
16.1%
5.7 pts better
|
19.8%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 8.7% · Q3 5.2% · Q4 8.3% · 4Q avg 10.4% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
6.2%
0.6 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.2% · Q3 7.9% · Q4 5.9% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
80.4%
18.3 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.4% · Q3 97.7% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
12.2%
1.4 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 13.7% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.2%
1.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
78.2%
16.9 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
24.2%
6 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 30.1% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-06 · Fire 2023-04-06
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2025-03-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-03-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-03-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-03-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-05-12
D · Potential for more than minimal harm
2023-04-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-03-28
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-05-12
Penalties and ownership
What sits behind the stars
Ownership
Bacon County Health Services, Inc.
Operational/Managerial Control · Organization
Bennett, Charlene
Corporate Director · Individual
Dubose, Cheryl
W-2 Managing Employee · Individual
Johnson, Daniel
Corporate Director · Individual
Jordan, Palmer
Corporate Director · Individual
Stanaland, Robert
Corporate Director · Individual
Staten, Roger
Corporate Director · Individual
Turner, Cindy
Corporate Director · Individual
Turner, Cindy
W-2 Managing Employee · Individual
Wildes, Albert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Appling Nursing And Rehabilitation Pavilion
Baxley, GA
1-star overall rating with 1-star inspections with Special Focus status with $18,966 in total fines with 7 recent health deficiencies
#2
Waycross Health And Rehabilitation
Waycross, GA
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Harborview Satilla
Waycross, GA
2-star overall rating with 2-star inspections with $9,620 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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