7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cartersville, GA
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
78 Opal Street, Cartersville, GA
(770) 382-6120
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
118
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Empire Care Centers
Operator or chain grouping
Approved since
1994-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 health / 1 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
RN hours / resident day
0.48
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.85
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
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
6,882
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.29
Baseline 24.35% · Performance 20.84% · Measure score 4.29 · Achievement 1.27 · Improvement 4.29
Healthcare-associated infections
6.17
Baseline 10.57% · Performance 6.85% · Measure score 6.17 · Achievement 3.28 · Improvement 6.17
Total nurse turnover
1.44
Performance 57.78% · Measure score 1.44 · Achievement 1.44 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.67
Baseline 2.58 hours · Performance 2.96 hours · Measure score 0.67 · Achievement 0 · Improvement 0.67
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.86% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 20.62% · Lower 95% interval 8.59% |
| Discharge to community | 39.47% |
50.57%
11.1 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 23.66% · Lower 95% interval 28.93% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 99 · Denominator 99 |
| Falls with major injury | 1.01% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 99 |
| Discharge self-care score | 61.36% |
53.69%
7.7 pts better
|
Numerator 27 · Denominator 44 |
| Discharge mobility score | 47.73% |
50.94%
3.2 pts worse
|
Numerator 21 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 1.01% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 99 · Adjusted rate 0.83% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 8.62% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 22.52% |
8.2%
14.3 pts better
|
Numerator 25 · Denominator 111 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 61.36% |
56.45%
4.9 pts better
|
Numerator 27 · Denominator 44 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 3.17% |
25.2%
22 pts worse
|
Numerator 2 · Denominator 63 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.3% |
91.2%
12.9 pts worse
|
93.4%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.2% · Q2 84.9% · Q3 91.4% · Q4 52.6% · 4Q avg 78.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.3% |
95.0%
12.7 pts worse
|
95.5%
13.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.2%
0.6 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.2% · Q3 3.2% · Q4 4.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
9.6%
6.9 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 3.8% · Q4 3.4% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
5.9%
1 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 3.4% · Q3 5.8% · Q4 7.9% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
20.7%
2.2 pts better
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 15.1% · Q3 16.7% · Q4 23.7% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
21.4%
10.4 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 7.7% · Q3 13.8% · Q4 12.9% · 4Q avg 11.0% · 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 | 16.1% |
17.9%
1.8 pts better
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 16.4% · Q3 5.2% · Q4 40.0% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
16.2%
0.3 pts better
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 4.7% · Q3 6.0% · Q4 42.0% · 4Q avg 15.9% · 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 | 0.8% |
2.5%
1.7 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 2.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
16.1%
11.1 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 29.4% · Q3 14.7% · Q4 33.4% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
6.2%
2.3 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.3% · Q3 4.6% · Q4 2.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
80.4%
2.4 pts worse
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 83.6% · Q3 88.4% · Q4 55.4% · 4Q avg 78.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.8% |
12.2%
8.4 pts better
|
12.0%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.8% · Observed 4.4% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
2.2%
1.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.7% |
78.2%
8.5 pts worse
|
79.7%
10 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.3% |
24.2%
4.1 pts worse
|
23.9%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 37.4% · Expected 31.4% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-06
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-06
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-06
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-06
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-06
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 2022-08-30
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-30
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-08-30
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-08-30
Fire Safety
Meet other general requirements.
Corrected 2019-06-02
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-06-02
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2019-06-02
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2019-06-02
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-29
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-29
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-29
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-29
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-29
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-05-26
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-05-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-06
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-06
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-06
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-06
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-06
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-06
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-06
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-06
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-06
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-06
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-06
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-08
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-08-07
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-07
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-07
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-08-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-30
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-08-30
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-08-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-30
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2022-08-30
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-30
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-08-30
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-08-30
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-08-30
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-08-30
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-08-30
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-08-30
Health
Respond appropriately to all alleged violations.
Corrected 2022-08-30
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-08-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-30
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 2022-08-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-30
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 2022-08-30
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-30
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Cartersville, GA
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Cartersville, GA
2-star overall rating with 3-star inspections with $6,784 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Kennesaw, GA
5-star overall rating with 4-star inspections with 3 recent health deficiencies
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