Cycle 1
Health 2025-03-20 · Fire 2025-03-20
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Waycross, GA
Waycross Health And Rehabilitation
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1910 Dorothy Street, Waycross, GA
(912) 285-4721
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
92
Certified beds
Average residents
64
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
0.86
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.25
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
0.57
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
0.93
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,829
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
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
Performance 8.41% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.91
Baseline 48.57% · Performance 51.79% · Measure score 2.91 · Achievement 2.91 · Improvement 0
Adjusted total nurse staffing
2.78
Baseline 3.53 hours · Performance 3.87 hours · Measure score 2.78 · Achievement 2.78 · Improvement 1
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 10.53% · Lower 95% interval 7.46% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · 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 | 89.47% |
95.27%
5.8 pts worse
|
Numerator 34 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 38.46% |
53.69%
15.2 pts worse
|
Numerator 10 · Denominator 26 |
| Discharge mobility score | 30.77% |
50.94%
20.2 pts worse
|
Numerator 8 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 2.63% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 38 · Adjusted rate 2.4% |
| Healthcare-associated infections requiring hospitalization | 8.41% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 109 |
| Staff flu vaccination coverage | 74.8% |
42%
32.8 pts better
|
Numerator 95 · Denominator 127 |
| Discharge function score | 42.31% |
56.45%
14.1 pts worse
|
Numerator 11 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28% |
25.2%
2.8 pts better
|
Numerator 7 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.7 |
2.2
1.5 pts worse
|
1.9
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
2.0
1.3 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.2%
8.4 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
95.0%
3.4 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| 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 1.8% · Q2 1.7% · Q3 3.2% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
9.6%
7.2 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 3.6% · Q4 1.8% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.9%
1.8 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 7.3% · Q3 5.1% · Q4 0.0% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
20.7%
3.9 pts worse
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 26.3% · Q3 23.0% · Q4 21.1% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
21.4%
0.6 pts worse
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 18.6% · Q3 25.0% · Q4 26.1% · 4Q avg 22.0% · 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 | 32.3% |
17.9%
14.4 pts worse
|
16.3%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
16.2%
0.3 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 23.1% · Q3 6.9% · Q4 15.1% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.5%
0.3 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 3.3% · Q4 1.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.5% |
16.1%
4.6 pts better
|
19.8%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 11.3% · Q3 11.5% · Q4 12.4% · 4Q avg 11.5% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.2%
About the same
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 4.5% · Q3 5.0% · Q4 3.2% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
80.4%
16 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 100.0% · Q3 97.4% · Q4 91.2% · 4Q avg 96.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.4% |
12.2%
4.2 pts worse
|
12.0%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 20.9% · Expected 14.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · 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 | 88.6% |
78.2%
10.4 pts better
|
79.7%
8.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
24.2%
3.5 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 34.9% · Expected 30.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-18 · Fire 2022-12-18
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-08-05 · Fire 2021-08-05
1 health deficiencies
Top issue: Resident Assessment and Care Planning (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
2025-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-04
F · Potential for more than minimal harm
2022-12-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-17
F · Potential for more than minimal harm
2022-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-17
F · Potential for more than minimal harm
2022-12-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-04
D · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-04
G · Actual harm
2022-12-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-17
E · Potential for more than minimal harm
2022-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-18
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 2023-01-17
D · Potential for more than minimal harm
2022-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-17
D · Potential for more than minimal harm
2021-08-05
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-09-03
Penalties and ownership
What sits behind the stars
Ownership
Clinical Services Inc
Operational/Managerial Control · Organization
Hodges, Kimberly
Operational/Managerial Control · Individual
Morton, William
Operational/Managerial Control · Individual
Simmons, Allyn
Operational/Managerial Control · Individual
Woods, Sonja
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
Baptist Village, Inc.
Waycross, GA
5-star overall rating with 5-star inspections with $10,218 in total fines with 7 fire-safety deficiencies in the latest cycle
#3
Bayview Nursing Home
Nahunta, GA
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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