Cycle 1
Health 2026-01-09 · Fire 2026-01-09
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rome, GA
Evergreen Health And Rehabilitation Center
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
139 Moran Lake Road, Ne, Rome, GA
(706) 378-3383
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-07-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.47
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,462
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9973
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.27
Baseline 21.49% · Performance 19.92% · Measure score 3.27 · Achievement 3.27 · Improvement 3.03
Healthcare-associated infections
5.3
Baseline 9.51% · Performance 6.89% · Measure score 5.3 · Achievement 3.15 · Improvement 5.3
Total nurse turnover
8.24
Baseline 58.82% · Performance 30.00% · Measure score 8.24 · Achievement 8.24 · Improvement 7.98
Adjusted total nurse staffing
0.87
Baseline 3.19 hours · Performance 3.32 hours · Measure score 0.87 · Achievement 0.87 · Improvement 0.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 11.59% · Lower 95% interval 7.51% |
| Discharge to community | 37.12% |
50.57%
13.5 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 20% · Lower 95% interval 22.65% |
| Medicare spending per beneficiary | 1.62 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 96.49% |
95.27%
1.2 pts better
|
Numerator 55 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 34.15% |
53.69%
19.5 pts worse
|
Numerator 14 · Denominator 41 |
| Discharge mobility score | 39.02% |
50.94%
11.9 pts worse
|
Numerator 16 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 10.53% |
2.29%
8.2 pts worse
|
Numerator 6 · Denominator 57 · Adjusted rate 11.94% |
| Healthcare-associated infections requiring hospitalization | 6.89% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 100 |
| Staff flu vaccination coverage | 15.7% |
42%
26.3 pts worse
|
Numerator 19 · Denominator 121 |
| Discharge function score | 36.59% |
56.45%
19.9 pts worse
|
Numerator 15 · Denominator 41 |
| 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 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 12.9% |
25.2%
12.3 pts worse
|
Numerator 4 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.2
0.4 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.7 · 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 | 91.8% |
95.0%
3.2 pts worse
|
95.5%
3.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.2%
3.6 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 6.7% · Q3 5.4% · Q4 4.5% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 77.1% |
9.6%
67.5 pts worse
|
11.4%
65.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 72.9% · Q3 76.4% · Q4 79.5% · 4Q avg 77.1% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.9%
1.1 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 10.3% · Q3 8.5% · Q4 3.8% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.5% |
20.7%
15.8 pts worse
|
19.6%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 37.6% · Q3 35.2% · Q4 37.6% · 4Q avg 36.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.0% |
21.4%
7.6 pts worse
|
16.7%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 31.2% · Q3 28.1% · Q4 26.6% · 4Q avg 29.0% · 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 | 23.3% |
17.9%
5.4 pts worse
|
16.3%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 30.5% · Q3 11.5% · Q4 19.3% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
16.2%
8.8 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 21.3% · Q3 17.7% · Q4 21.3% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.1%
0.2 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 1.1% · Q4 1.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.5%
0.1 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 3.5% · Q4 4.8% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.5% |
16.1%
8.6 pts better
|
19.8%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 7.6% · Q3 3.0% · Q4 7.4% · 4Q avg 7.5% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
6.2%
1.3 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 4.1% · Q3 10.5% · Q4 5.7% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
80.4%
19.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
12.2%
4.2 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 9.6% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
2.2%
0.2 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 52.4% |
78.2%
25.8 pts worse
|
79.7%
27.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 52.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
24.2%
5.9 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 24.7% · Expected 32.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-18 · Fire 2024-08-18
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2026-02-23
F · Potential for more than minimal harm
2026-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-23
D · Potential for more than minimal harm
2026-01-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-23
E · Potential for more than minimal harm
2024-08-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-18
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 2024-09-26
D · Potential for more than minimal harm
2024-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-18
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-09-26
F · Potential for more than minimal harm
2022-10-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-11
F · Potential for more than minimal harm
2022-10-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-09
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 2026-02-27
D · Potential for more than minimal harm
2026-01-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-27
F · Potential for more than minimal harm
2025-09-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-11-20
E · Potential for more than minimal harm
2025-09-05
F584 · Resident Rights Deficiencies
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 2025-11-20
E · Potential for more than minimal harm
2025-09-05
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 2025-11-20
D · Potential for more than minimal harm
2025-09-05
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 2025-11-20
D · Potential for more than minimal harm
2025-09-05
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 2025-11-20
D · Potential for more than minimal harm
2024-08-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-18
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 2024-09-26
D · Potential for more than minimal harm
2024-08-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-26
D · Potential for more than minimal harm
2023-06-21
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 2023-08-07
Penalties and ownership
What sits behind the stars
Ownership
Prince Equities LLC
5% Or Greater Direct Ownership Interest · Organization
Landers, Lisa
Operational/Managerial Control · Individual
Landers, Lisa
Corporate Officer · Individual
Landers, Lisa
W-2 Managing Employee · Individual
Prince Equities LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Winthrop Health And Rehabilitation
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Fifth Avenue Health Care
Rome, GA
1-star overall rating with 2-star inspections with $8,512 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Etowah Landing
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1-star overall rating with 1-star inspections with $88,205 in total fines with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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