Cycle 1
Health 2025-04-10 · Fire 2025-04-10
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Barnesville, GA
Heritage Inn Of Barnesville Health And Rehab
3-star overall rating with 4-star inspections with 2 recent health deficiencies
946 Veterans Parkway, Barnesville, GA
(770) 358-2485
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
108
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1989-11-01
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
0.13
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.03
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.79
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.09
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.15
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,657
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
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
4.38
Baseline 64.86% · Performance 45.78% · Measure score 4.38 · Achievement 4.38 · Improvement 4.27
Adjusted total nurse staffing
2.70
Baseline 3.38 hours · Performance 3.85 hours · Measure score 2.70 · Achievement 2.70 · Improvement 1.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.05% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 7.2% |
| Discharge to community | 34.59% |
50.57%
16 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 19.23% · Lower 95% interval 20.74% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0.72% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 139 |
| Staff flu vaccination coverage | 7.14% |
42%
34.9 pts worse
|
Numerator 9 · Denominator 126 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.2
0.4 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 44.1% |
91.2%
47.1 pts worse
|
93.4%
49.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.1% · Q2 45.5% · Q3 41.3% · Q4 41.7% · 4Q avg 44.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.1% |
95.0%
3.9 pts worse
|
95.5%
4.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
3.2%
4.1 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.1% · Q3 8.7% · Q4 8.7% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
9.6%
5.6 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 1.1% · Q3 7.3% · Q4 1.1% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
5.9%
4.4 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 14.9% · Q3 6.2% · Q4 12.0% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.6% |
20.7%
3.9 pts worse
|
19.6%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 22.3% · Q3 26.8% · Q4 24.7% · 4Q avg 24.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.0% |
21.4%
4.6 pts worse
|
16.7%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 26.3% · Q3 26.9% · Q4 25.7% · 4Q avg 26.0% · 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 | 14.2% |
17.9%
3.7 pts better
|
16.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 15.4% · Q3 15.0% · Q4 13.0% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
16.2%
0.3 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 14.3% · Q3 14.9% · Q4 21.2% · 4Q avg 16.5% · 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 1.6% · Q2 1.0% · Q3 1.6% · Q4 0.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.9% |
2.5%
4.4 pts worse
|
1.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.1% · Q3 7.7% · Q4 6.9% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.7% |
16.1%
0.4 pts better
|
19.8%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 24.1% · Q3 12.6% · Q4 9.8% · 4Q avg 15.7% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
6.2%
2 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.5% · Q3 4.2% · Q4 3.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.2% |
80.4%
45.2 pts worse
|
81.7%
46.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 27.0% · Q3 37.0% · Q4 25.9% · 4Q avg 35.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 25.7% |
78.2%
52.5 pts worse
|
79.7%
54 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-23 · Fire 2023-02-23
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-09-03 · Fire 2021-09-03
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-10
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 2025-05-25
D · Potential for more than minimal harm
2025-04-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-25
D · Potential for more than minimal harm
2024-02-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-02-15
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 2024-03-25
D · Potential for more than minimal harm
2024-02-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-25
B · Minimal harm
2024-02-15
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-03-25
B · Minimal harm
2024-02-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-25
D · Potential for more than minimal harm
2023-02-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-09
D · Potential for more than minimal harm
2023-02-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-09
D · Potential for more than minimal harm
2023-02-23
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-09
D · Potential for more than minimal harm
2023-02-23
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 2023-04-09
D · Potential for more than minimal harm
2023-02-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-09
D · Potential for more than minimal harm
2023-02-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-09
D · Potential for more than minimal harm
2021-09-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-10-18
Penalties and ownership
What sits behind the stars
Ownership
Community Health Systems Inc
5% Or Greater Indirect Ownership Interest · Organization
Clinical Services Inc
Operational/Managerial Control · Organization
Curtis, Rikeah
Operational/Managerial Control · Individual
Health Systems Facilities Inc
5% Or Greater Direct Ownership Interest · Organization
Heritage Inn Of Barnesville LLC
5% Or Greater Direct Ownership Interest · Organization
Pittman, Jacqueline
Operational/Managerial Control · Individual
Reese, Cynthia
Operational/Managerial Control · Individual
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#3
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