Cycle 1
Health 2025-09-11 · Fire 2025-09-11
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Douglas, GA
Vista Park Health And Rehabilitation
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1310 West Gordon Street, Douglas, GA
(912) 384-7811
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
130
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1996-10-01
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
0.32
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.08
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
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,565
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.61% · Performance 22.13% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.96
Baseline 9.26% · Performance 7.79% · Measure score 2.96 · Achievement 0 · Improvement 2.96
Total nurse turnover
8.78
Baseline 50.00% · Performance 27.78% · Measure score 8.78 · Achievement 8.78 · Improvement 8.34
Adjusted total nurse staffing
4.03
Baseline 3.47 hours · Performance 4.22 hours · Measure score 4.03 · Achievement 4.03 · Improvement 2.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.84% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 10.29% · Lower 95% interval 7.75% |
| Discharge to community | 56.29% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 53.1% · Lower 95% interval 48.79% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.43% |
95.27%
3.2 pts better
|
Numerator 125 · Denominator 127 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 127 |
| Discharge self-care score | 43.43% |
53.69%
10.3 pts worse
|
Numerator 43 · Denominator 99 |
| Discharge mobility score | 35.35% |
50.94%
15.6 pts worse
|
Numerator 35 · Denominator 99 |
| Pressure ulcers or injuries, new or worsened | 1.57% |
2.29%
0.7 pts better
|
Numerator 2 · Denominator 127 · Adjusted rate 1.6% |
| Healthcare-associated infections requiring hospitalization | 7.79% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 108 · Observed rate 7.41% · Lower 95% interval 4.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 142 |
| Staff flu vaccination coverage | 48.41% |
42%
6.4 pts better
|
Numerator 76 · Denominator 157 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 33 · Denominator 99 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 74 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 13.85% |
25.2%
11.3 pts worse
|
Numerator 9 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.2%
8.1 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 97.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| 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 | 1.2% |
3.2%
2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 0.0% · Q4 0.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
9.6%
8.5 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
5.9%
5 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 9.3% · Q3 10.5% · Q4 10.4% · 4Q avg 10.9% |
| 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 29.6% · Q2 33.7% · Q3 31.6% · Q4 30.8% · 4Q avg 31.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.2% |
21.4%
2.8 pts worse
|
16.7%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 16.9% · Q3 26.2% · Q4 28.6% · 4Q avg 24.2% · 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 | 15.4% |
17.9%
2.5 pts better
|
16.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 16.2% · Q3 18.8% · Q4 18.7% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
16.2%
3 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 13.0% · Q3 9.4% · Q4 16.3% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.1%
1.1 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 1.6% · Q4 2.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.5%
0.7 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 3.0% · Q4 0.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.3% |
16.1%
0.8 pts better
|
19.8%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 17.3% · Q3 13.5% · Q4 17.6% · 4Q avg 15.3% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
6.2%
1.6 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 8.1% · Q3 9.4% · Q4 7.1% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
80.4%
17.2 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 96.4% · Q3 97.6% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
12.2%
6.1 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 5.7% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
2.2%
1.3 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.1% · Q3 4.4% · Q4 7.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
78.2%
18.9 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.3% |
24.2%
9.1 pts worse
|
23.9%
9.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.3% · Observed 30.7% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-04-15 · Fire 2022-04-15
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
2025-09-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-09-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-09-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-12-03
F · Potential for more than minimal harm
2024-03-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-26
D · Potential for more than minimal harm
2025-09-11
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 2025-10-26
D · Potential for more than minimal harm
2024-03-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-07
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 2024-04-21
D · Potential for more than minimal harm
2024-03-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-21
Penalties and ownership
What sits behind the stars
Ownership
Adams, Tara
Operational/Managerial Control · Individual
Clinical Services Inc
Operational/Managerial Control · Organization
Hill, Stacey
Operational/Managerial Control · Individual
Satchell, Michael
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Twin Oaks Convalescent Center
Alma, GA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Palemon Gaskins Mem Nsg Home
Ocilla, GA
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Ocilla
Ocilla, GA
2-star overall rating with 4-star inspections with 7 recent health deficiencies
Jump out