Cycle 1
Health 2025-04-10 · Fire 2025-04-10
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cartersville, GA
Townsend Park Health And Rehabilitation
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
196 North Dixie Avenue, Cartersville, GA
(770) 387-0662
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
121
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1989-11-27
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
0.36
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.87
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,717
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9919
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.87
Baseline 22.25% · Performance 20.49% · Measure score 2.87 · Achievement 2.03 · Improvement 2.87
Healthcare-associated infections
2.40
Baseline 8.38% · Performance 7.40% · Measure score 2.40 · Achievement 1.45 · Improvement 2.40
Total nurse turnover
7.29
Baseline 55.70% · Performance 33.90% · Measure score 7.29 · Achievement 7.29 · Improvement 6.57
Adjusted total nurse staffing
2.99
Baseline 3.55 hours · Performance 3.93 hours · Measure score 2.99 · Achievement 2.99 · Improvement 1.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.79% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 3.85% · Lower 95% interval 5.95% |
| Discharge to community | 55.07% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 51.02% · Lower 95% interval 44.3% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 79.17% |
95.27%
16.1 pts worse
|
Numerator 76 · Denominator 96 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 96 |
| Discharge self-care score | 53.25% |
53.69%
0.4 pts worse
|
Numerator 41 · Denominator 77 |
| Discharge mobility score | 46.75% |
50.94%
4.2 pts worse
|
Numerator 36 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 3 · Denominator 96 · Adjusted rate 3.23% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 7.35% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 0.67% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 150 |
| Staff flu vaccination coverage | 54.55% |
42%
12.5 pts better
|
Numerator 90 · Denominator 165 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 42 · Denominator 77 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.67% |
96.28%
1.4 pts better
|
Numerator 42 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 17.02% |
25.2%
8.2 pts worse
|
Numerator 8 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.2
0.2 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.0
1.1 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 61.6% |
91.2%
29.6 pts worse
|
93.4%
31.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 51.4% · Q3 62.8% · Q4 80.0% · 4Q avg 61.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
95.0%
1.4 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.2%
1.8 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.8% · Q3 3.5% · Q4 7.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
9.6%
2.6 pts better
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 11.3% · Q3 5.8% · Q4 4.7% · 4Q avg 7.0% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.9%
0.6 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.6% · Q3 6.2% · Q4 9.1% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.0% |
20.7%
2.3 pts worse
|
19.6%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 23.9% · Q3 22.2% · Q4 22.0% · 4Q avg 23.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.1% |
21.4%
9.7 pts worse
|
16.7%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 31.2% · Q3 32.2% · Q4 32.2% · 4Q avg 31.1% · 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 | 17.2% |
17.9%
0.7 pts better
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 22.9% · Q3 11.4% · Q4 15.3% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.2% |
16.2%
1 pts worse
|
14.9%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 11.8% · Q3 18.3% · Q4 17.4% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.1%
1 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.2% · Q3 1.5% · Q4 0.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.5%
0.4 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.9% · Q3 0.9% · Q4 6.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.5% |
16.1%
1.6 pts better
|
19.8%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 18.9% · Q3 6.8% · Q4 12.8% · 4Q avg 14.5% |
| 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 8.4% · Q2 4.0% · Q3 3.4% · Q4 0.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.6% |
80.4%
44.8 pts worse
|
81.7%
46.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 31.5% · Q3 47.4% · Q4 50.0% · 4Q avg 35.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
12.2%
3.3 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 8.2% · Expected 10.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.8% |
78.2%
23.4 pts worse
|
79.7%
24.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
24.2%
3.1 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 18.0% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-27 · Fire 2023-04-27
10 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-10
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 2025-05-23
D · Potential for more than minimal harm
2025-04-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-23
F · Potential for more than minimal harm
2023-04-27
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 2023-06-11
E · Potential for more than minimal harm
2023-04-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-11
F · Potential for more than minimal harm
2021-07-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-05
E · Potential for more than minimal harm
2021-07-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-09-05
E · Potential for more than minimal harm
2021-07-22
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-09-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-10
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-10
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 2025-05-23
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 2025-05-23
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
F · Potential for more than minimal harm
2023-04-27
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-06-11
F · Potential for more than minimal harm
2023-04-27
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 2023-06-11
E · Potential for more than minimal harm
2023-04-27
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 2023-06-11
E · Potential for more than minimal harm
2023-04-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-11
E · Potential for more than minimal harm
2023-04-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
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 2023-06-11
D · Potential for more than minimal harm
2023-04-27
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 2023-06-11
D · Potential for more than minimal harm
2023-04-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-11
D · Potential for more than minimal harm
2023-04-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-11
Penalties and ownership
What sits behind the stars
Ownership
Community Health Systems Inc
5% Or Greater Indirect Ownership Interest · Organization
Health Scholarships Inc
5% Or Greater Direct Ownership Interest · Organization
Blake, Wyatt
Operational/Managerial Control · Individual
Burger, Maxic
Operational/Managerial Control · Individual
Burk, Traci
Operational/Managerial Control · Individual
Clinical Services Inc
Operational/Managerial Control · Organization
Lambert, Reno
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Cartersville Center For Nursing And Healing
Cartersville, GA
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Cartersville Crossing Of Journey LLC
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
#3
Chulio Hills Health And Rehab
Rome, GA
1-star overall rating with 2-star inspections with $4,017 in total fines with 9 recent health deficiencies
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