Cycle 1
Health 2025-09-11 · Fire 2025-09-11
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Royston, GA
Brown Health and Rehabilitation
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
545 Cook Street, Royston, GA
(706) 245-1900
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
94
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1968-12-04
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
0.51
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.98
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.31
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
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,626
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.83% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.66
Baseline 6.29% · Performance 7.04% · Measure score 2.66 · Achievement 2.66 · Improvement 0
Total nurse turnover
4.22
Baseline 58.82% · Performance 46.43% · Measure score 4.22 · Achievement 4.22 · Improvement 3.15
Adjusted total nurse staffing
3.59
Baseline 3.19 hours · Performance 4.10 hours · Measure score 3.59 · Achievement 3.59 · Improvement 3.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.49% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 6.8% · Lower 95% interval 6.65% |
| Discharge to community | 47.57% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 40.45% · Lower 95% interval 37.23% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 52 · Denominator 53 |
| Falls with major injury | 1.89% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 53 |
| Discharge self-care score | 11.11% |
53.69%
42.6 pts worse
|
Numerator 4 · Denominator 36 |
| Discharge mobility score | 11.11% |
50.94%
39.8 pts worse
|
Numerator 4 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 3.77% |
2.29%
1.5 pts worse
|
Numerator 2 · Denominator 53 · Adjusted rate 2.89% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 7.35% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 2.22% |
8.2%
6 pts worse
|
Numerator 3 · Denominator 135 |
| Staff flu vaccination coverage | 82.04% |
42%
40 pts better
|
Numerator 137 · Denominator 167 |
| Discharge function score | 19.44% |
56.45%
37 pts worse
|
Numerator 7 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| 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 | 10% |
25.2%
15.2 pts worse
|
Numerator 2 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.0
1.4 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · 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 | 4.9% |
3.2%
1.7 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.9% · Q3 3.8% · Q4 4.9% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.2% |
9.6%
21.6 pts worse
|
11.4%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.3% · Q2 37.5% · Q3 30.3% · Q4 13.6% · 4Q avg 31.2% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.9%
0.8 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.3% · Q3 4.2% · Q4 6.8% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.3% |
20.7%
5.6 pts worse
|
19.6%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 22.7% · Q3 26.8% · Q4 35.1% · 4Q avg 26.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.2% |
21.4%
5.8 pts worse
|
16.7%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 23.3% · Q3 29.1% · Q4 30.2% · 4Q avg 27.2% · 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 | 16.8% |
17.9%
1.1 pts better
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 28.9% · Q3 11.0% · Q4 14.8% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.4% |
16.2%
8.2 pts worse
|
14.9%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 32.9% · Q3 22.7% · Q4 22.4% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.5%
About the same
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 1.2% · Q3 1.3% · Q4 1.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
16.1%
2.1 pts worse
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 17.2% · Q3 20.5% · Q4 16.5% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
6.2%
2.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.9% · Q3 2.3% · Q4 2.4% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
80.4%
13.4 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 98.2% · Q3 98.2% · Q4 86.2% · 4Q avg 93.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.9% |
12.2%
13.7 pts worse
|
12.0%
13.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 27.3% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.2% |
2.2%
4 pts worse
|
1.6%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.0% · Q4 8.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
78.2%
18.4 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
24.2%
1 pts better
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 24.2% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-09-11
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-11-10
D · Potential for more than minimal harm
2024-04-05
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 2024-05-20
D · Potential for more than minimal harm
2024-04-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-05
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-05-20
F · Potential for more than minimal harm
2023-02-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
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 2025-11-19
D · Potential for more than minimal harm
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-19
E · Potential for more than minimal harm
2024-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-05
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-05
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 2024-05-22
D · Potential for more than minimal harm
2024-04-05
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 2024-05-22
D · Potential for more than minimal harm
2024-04-05
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-05-22
E · Potential for more than minimal harm
2023-02-16
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 2023-04-14
E · Potential for more than minimal harm
2023-02-16
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 2023-04-14
E · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
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 2023-04-14
D · Potential for more than minimal harm
2023-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-02-16
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-14
Penalties and ownership
What sits behind the stars
Ownership
Cable, Paul
Corporate Director · Individual
Clinical Services Inc
Operational/Managerial Control · Organization
Community Health Systems Inc
5% Or Greater Direct Ownership Interest · Organization
Dennis, Kathryn
Corporate Director · Individual
Esco, Dana
Operational/Managerial Control · Individual
Franklin County Holdings, LLC
5% Or Greater Mortgage Interest · Organization
Gipson, Tana
Operational/Managerial Control · Individual
Health Scholarships Inc
5% Or Greater Direct Ownership Interest · Organization
Lambert, Reno
Operational/Managerial Control · Individual
Moody, Teresa
Corporate Officer · Individual
Nichols, Joseph
Corporate Director · Individual
Rollins, Ronnie
Corporate Director · Individual
Wall, Joseph
Corporate Director · Individual
Warnock, Ralph
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Comer Health And Rehabilitation
Comer, GA
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Hartwell Health And Rehabilitation
Hartwell, GA
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Hart Care Center
Hartwell, GA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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