Rome, GA

Winthrop Health And Rehabilitation

4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

12 Chateau Drive, Rome, GA

(706) 235-1422

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

80

Certified beds

Average residents

79

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Ethica Health

Operator or chain grouping

Approved since

1989-07-01

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

0.74

Registered nurse staffing · state 0.49 · national 0.68

LPN hours / resident day

0.25

Licensed practical nurse staffing · state 0.93 · national 0.87

Aide hours / resident day

2.27

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.27

All reported nurse hours · state 3.57 · national 3.89

Licensed hours

0.99

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

2.81

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.50

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

0.79

CMS adjusted RN staffing hours

Adjusted total hours

3.50

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

39%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,722

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

Performance score

15.57

Composite VBP score used to determine payment impact.

Payment multiplier

0.9815

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 19.31% · Performance 24.14% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0

Baseline 7.70% · Performance 7.88% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.43

Baseline 72.22% · Performance 53.62% · Measure score 3.43 · Achievement 2.46 · Improvement 3.43

Adjusted total nurse staffing

2.80

Baseline 3.06 hours · Performance 3.88 hours · Measure score 2.80 · Achievement 2.80 · Improvement 2.50

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.11%	10.72% 1.6 pts better	No Different than the National Rate · Eligible stays 65 · Observed rate 4.62% · Lower 95% interval 6.27%
Discharge to community	47.26%	50.57% 3.3 pts worse	No Different than the National Rate · Eligible stays 58 · Observed rate 37.93% · Lower 95% interval 34.54%
Medicare spending per beneficiary	0.87	1.02 0.2 pts better
Drug regimen review with follow-up	90.2%	95.27% 5.1 pts worse	Numerator 46 · Denominator 51
Falls with major injury	1.96%	0.77% 1.2 pts worse	Numerator 1 · Denominator 51
Discharge self-care score	29.41%	53.69% 24.3 pts worse	Numerator 10 · Denominator 34
Discharge mobility score	29.41%	50.94% 21.5 pts worse	Numerator 10 · Denominator 34
Pressure ulcers or injuries, new or worsened	3.92%	2.29% 1.6 pts worse	Numerator 2 · Denominator 51 · Adjusted rate 3.72%
Healthcare-associated infections requiring hospitalization	7.88%	7.12% 0.8 pts worse	No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 4.48%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 123
Staff flu vaccination coverage	80.6%	42% 38.6 pts better	Numerator 108 · Denominator 134
Discharge function score	35.29%	56.45% 21.2 pts worse	Numerator 12 · Denominator 34
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 15 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	10.71%	25.2% 14.5 pts worse	Numerator 3 · Denominator 28

Quality measures

Resident outcomes and process scores

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 2.0 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	2.0 1 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	93.4%	91.2% 2.2 pts better	93.4% About the same	Long Stay · 2024Q4-2025Q3 · Q1 84.1% · Q2 100.0% · Q3 98.6% · Q4 91.0% · 4Q avg 93.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.8%	95.0% 0.2 pts worse	95.5% 0.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8%
Percentage of long-stay residents experiencing one or more falls with major injury	5.9%	3.2% 2.7 pts worse	3.3% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 8.5% · Q3 5.6% · Q4 6.4% · 4Q avg 5.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.8%	9.6% 8.8 pts better	11.4% 10.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8%
Percentage of long-stay residents who lose too much weight	6.4%	5.9% 0.5 pts worse	5.4% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 8.5% · Q3 7.1% · Q4 4.9% · 4Q avg 6.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	27.4%	20.7% 6.7 pts worse	19.6% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.8% · Q3 27.6% · Q4 31.1% · 4Q avg 27.4%
Percentage of long-stay residents who received an antipsychotic medication	22.0%	21.4% 0.6 pts worse	16.7% 5.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 25.5% · Q3 22.0% · Q4 20.0% · 4Q avg 22.0% · 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	18.2%	17.9% 0.3 pts worse	16.3% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 17.7% · Q3 35.1% · Q4 4.9% · 4Q avg 18.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.0%	16.2% 2.8 pts worse	14.9% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 24.1% · Q3 22.6% · Q4 12.1% · 4Q avg 19.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	3.8%	1.1% 2.7 pts worse	1.0% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.5% · Q3 5.8% · Q4 3.2% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.2%	2.5% 0.7 pts worse	1.7% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.9% · Q3 1.4% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	8.8%	16.1% 7.3 pts better	19.8% 11 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.4% · Q3 9.1% · Q4 14.4% · 4Q avg 8.8%
Percentage of long-stay residents with pressure ulcers	4.4%	6.2% 1.8 pts better	5.1% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 2.4% · Q3 3.5% · Q4 3.2% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	63.6%	80.4% 16.8 pts worse	81.7% 18.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 64.2% · Q3 65.3% · Q4 50.0% · 4Q avg 63.6%
Percentage of short-stay residents who had an outpatient emergency department visit	6.4%	12.2% 5.8 pts better	12.0% 5.6 pts better	Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 6.2% · Expected 10.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	4.0%	2.2% 1.8 pts worse	1.6% 2.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.0% · Q3 3.8% · 4Q avg 4.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	67.9%	78.2% 10.3 pts worse	79.7% 11.8 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 67.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.2%	24.2% 1 pts worse	23.9% 1.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 27.1% · Expected 25.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-18 · Fire 2025-09-18

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2024-06-09 · Fire 2024-06-09

3 health deficiencies

Top issue: Infection Control (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-05-16 · Fire 2022-05-16

12 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-09-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-12-04

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-18

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 2025-10-10

D · Potential for more than minimal harm 2025-09-18

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-10-10

D · Potential for more than minimal harm 2025-09-18

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-10-10

F · Potential for more than minimal harm 2024-06-09

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-06-30

F · Potential for more than minimal harm 2024-06-09

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 2024-06-30

D · Potential for more than minimal harm 2024-06-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-30

J · Immediate jeopardy 2022-05-16

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 2022-06-06

J · Immediate jeopardy 2022-05-16

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2022-06-06

J · Immediate jeopardy 2022-05-16

F608 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.

Corrected 2022-06-06

J · Immediate jeopardy 2022-05-16

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-06-06

J · Immediate jeopardy 2022-05-16

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 2022-06-06

J · Immediate jeopardy 2022-05-16

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2022-06-06