Cycle 1
Health 2025-06-20 · Fire 2025-06-20
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Albany, GA
Wynfield Park Health And Rehabilitation
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
223 W.third Avenue, Albany, GA
(229) 435-0741
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
186
Certified beds
Average residents
155
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1997-01-01
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
0.77
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.26
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.03
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,566
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.25% · Performance 22.69% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.15% · Performance 11.78% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.81
Baseline 57.98% · Performance 44.02% · Measure score 4.81 · Achievement 4.81 · Improvement 3.71
Adjusted total nurse staffing
3.16
Baseline 3.39 hours · Performance 3.98 hours · Measure score 3.16 · Achievement 3.16 · Improvement 1.96
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.28% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 111 · Observed rate 12.61% · Lower 95% interval 8.2% |
| Discharge to community | 35.8% |
50.57%
14.8 pts worse
|
Worse than the National Rate · Eligible stays 109 · Observed rate 27.52% · Lower 95% interval 26.82% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.64% |
95.27%
0.6 pts worse
|
Numerator 106 · Denominator 112 |
| Falls with major injury | 5.36% |
0.77%
4.6 pts worse
|
Numerator 6 · Denominator 112 |
| Discharge self-care score | 26.25% |
53.69%
27.4 pts worse
|
Numerator 21 · Denominator 80 |
| Discharge mobility score | 22.5% |
50.94%
28.4 pts worse
|
Numerator 18 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 7 · Denominator 112 · Adjusted rate 4.83% |
| Healthcare-associated infections requiring hospitalization | 11.78% |
7.12%
4.7 pts worse
|
Worse than the National Rate · Eligible stays 84 · Observed rate 17.86% · Lower 95% interval 7.96% |
| Staff COVID-19 vaccination coverage | 0.47% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 215 |
| Staff flu vaccination coverage | 48.62% |
42%
6.6 pts better
|
Numerator 106 · Denominator 218 |
| Discharge function score | 23.75% |
56.45%
32.7 pts worse
|
Numerator 19 · Denominator 80 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 86.84% |
96.28%
9.4 pts worse
|
Numerator 33 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 40.68% |
25.2%
15.5 pts better
|
Numerator 24 · Denominator 59 |
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 2.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
91.2%
6.7 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 100.0% · Q3 100.0% · Q4 94.3% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
95.0%
3.1 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.2%
0.7 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.8% · Q3 2.9% · Q4 2.1% · 4Q avg 2.5% · 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 | 5.2% |
5.9%
0.7 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 6.0% · Q3 4.8% · Q4 3.8% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
20.7%
3.3 pts better
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.2% · Q3 15.5% · Q4 17.4% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.7% |
21.4%
8.3 pts worse
|
16.7%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 35.4% · Q3 31.6% · Q4 28.6% · 4Q avg 29.7% · 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 | 18.3% |
17.9%
0.4 pts worse
|
16.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 19.6% · Q3 17.0% · Q4 19.9% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
16.2%
4.8 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 31.6% · Q3 17.1% · Q4 16.4% · 4Q avg 21.0% · 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 1.4% · Q2 0.4% · Q3 0.4% · Q4 0.9% · 4Q avg 0.8% · 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 0.7% · Q2 2.2% · Q3 2.2% · Q4 0.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.9% |
16.1%
5.2 pts better
|
19.8%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 13.2% · Q3 10.4% · Q4 7.9% · 4Q avg 10.9% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
6.2%
5.1 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 11.1% · Q3 10.2% · Q4 11.3% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.3% |
80.4%
3.9 pts better
|
81.7%
2.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.2% · Q2 86.0% · Q3 87.8% · Q4 82.9% · 4Q avg 84.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
12.2%
4.4 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.6% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
2.2%
1.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.0% |
78.2%
12.8 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.9% |
24.2%
4.7 pts worse
|
23.9%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.9% · Observed 28.3% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-10 · Fire 2023-08-10
3 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-12-17 · Fire 2021-12-17
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
2025-06-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-20
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-08-05
D · Potential for more than minimal harm
2023-08-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-06-20
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-06-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-06-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-06-20
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 2025-08-04
D · Potential for more than minimal harm
2025-06-20
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-06-20
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 2025-08-04
D · Potential for more than minimal harm
2025-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-04
D · Potential for more than minimal harm
2024-11-07
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-07-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-12
D · Potential for more than minimal harm
2023-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-24
Penalties and ownership
What sits behind the stars
Ownership
Burnett, Kelly
Operational/Managerial Control · Individual
Clinical Services Inc
Operational/Managerial Control · Organization
Hodges, Kimberly
Operational/Managerial Control · Individual
Satchell, Michael
Operational/Managerial Control · Individual
Stocking, Sharon
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Pruitthealth - Palmyra
Albany, GA
1-star overall rating with 1-star inspections with Special Focus status with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Lee County Health And Rehabilitation
Leesburg, GA
3-star overall rating with 3-star inspections with $16,800 in total fines with 3 fire-safety deficiencies in the latest cycle
#3
Pruitthealth - Sylvester
Sylvester, GA
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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