Eatonton, GA

Eatonton Health And Rehabilitation

3-star overall rating with 3-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

125 Sparta Highway 16 East, Eatonton, GA

(706) 485-8573

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 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

104

Certified beds

Average residents

75

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Ethica Health

Operator or chain grouping

Approved since

1996-02-01

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

0.33

Registered nurse staffing · state 0.49 · national 0.68

LPN hours / resident day

0.62

Licensed practical nurse staffing · state 0.93 · national 0.87

Aide hours / resident day

1.97

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

2.93

All reported nurse hours · state 3.57 · national 3.89

Licensed hours

0.95

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

2.40

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.14

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

0.38

CMS adjusted RN staffing hours

Adjusted total hours

3.34

CMS adjusted total nurse staffing hours

Case-mix index

1.20

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

37%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,993

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

46.53

Composite VBP score used to determine payment impact.

Payment multiplier

0.9999

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

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

6.34

Baseline 41.46% · Performance 37.78% · Measure score 6.34 · Achievement 6.34 · Improvement 1.72

Adjusted total nurse staffing

2.97

Baseline 3.35 hours · Performance 3.92 hours · Measure score 2.97 · Achievement 2.97 · Improvement 1.86

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.14%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 6.75%
Discharge to community	50.2%	50.57% 0.4 pts worse	No Different than the National Rate · Eligible stays 30 · Observed rate 40% · Lower 95% interval 33.06%
Medicare spending per beneficiary	1.02	1.02 About the same
Drug regimen review with follow-up	80.95%	95.27% 14.3 pts worse	Numerator 17 · Denominator 21
Falls with major injury	4.76%	0.77% 4 pts worse	Numerator 1 · Denominator 21
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 21 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	3.19%	8.2% 5 pts worse	Numerator 3 · Denominator 94
Staff flu vaccination coverage	67.39%	42% 25.4 pts better	Numerator 62 · Denominator 92
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.2%	91.2% 8 pts better	93.4% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.7% · Q4 100.0% · 4Q avg 99.2%
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	5.1%	3.2% 1.9 pts worse	3.3% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 5.5% · Q3 4.9% · Q4 1.5% · 4Q avg 5.1% · 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	4.5%	5.9% 1.4 pts better	5.4% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 13.7% · Q3 0.0% · Q4 0.0% · 4Q avg 4.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.6%	20.7% 7.9 pts worse	19.6% 9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 25.5% · Q3 29.8% · Q4 29.5% · 4Q avg 28.6%
Percentage of long-stay residents who received an antipsychotic medication	30.3%	21.4% 8.9 pts worse	16.7% 13.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 32.5% · Q3 31.2% · Q4 28.8% · 4Q avg 30.3% · 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	16.3%	17.9% 1.6 pts better	16.3% About the same	Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q4 12.2% · 4Q avg 16.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.8%	16.2% 4.4 pts better	14.9% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 8.5% · Q3 13.2% · Q4 8.6% · 4Q avg 11.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	1.1% About the same	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.3%	2.5% 1.2 pts better	1.7% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 0.0% · Q4 1.5% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	10.7%	16.1% 5.4 pts better	19.8% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 11.6% · Q3 12.7% · Q4 4.6% · 4Q avg 10.7%
Percentage of long-stay residents with pressure ulcers	9.3%	6.2% 3.1 pts worse	5.1% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 9.0% · Q3 8.1% · Q4 11.6% · 4Q avg 9.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	87.0%	80.4% 6.6 pts better	81.7% 5.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 87.0% · Q3 92.9% · Q4 82.2% · 4Q avg 87.0%
Percentage of short-stay residents who newly received an antipsychotic medication	1.7%	2.2% 0.5 pts better	1.6% 0.1 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	80.0%	78.2% 1.8 pts better	79.7% 0.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-26 · Fire 2025-06-26

8 health deficiencies

Top issue: Resident Rights (3 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-01-28 · Fire 2024-01-28

8 health deficiencies

Top issue: Infection Control (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2022-08-14 · Fire 2022-08-14

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

E · Potential for more than minimal harm 2025-06-26

K371 · Smoke Deficiencies

Fire Safety

Have properly sized and located compartments to protect residents from smoke.

Corrected 2025-08-10

E · Potential for more than minimal harm 2025-06-26

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-08-10

F · Potential for more than minimal harm 2024-01-28

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-03-13

D · Potential for more than minimal harm 2024-01-28

K364 · Smoke Deficiencies

Fire Safety

Install properly constructed windows in hallway walls or doors.

Corrected 2024-03-13

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-06-26

F761 · Pharmacy Service Deficiencies

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 2025-07-21