Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Townsend Park Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with wounds and skin breakdown received perineal care from two CNAs who wore gloves but not gowns, despite EBP criteria being met. One CNA then left the room wearing soiled gloves, carried soiled linen and a brief into the hallway, disposed of them in hallway receptacles, and only then removed the gloves and performed hand hygiene. The resident had diagnoses including pressure ulcers, diabetes, and CKD, and the DON confirmed the resident should have been on EBP.
Five CNAs did not receive required annual performance evaluations, as confirmed by personnel file reviews and staff interviews. The facility's policy mandates annual evaluations, but neither the ADON nor department managers ensured completion, and the HR Director confirmed the absence of these evaluations.
A resident with severe cognitive impairment was found to have a wrist fracture of unknown origin, with no documented falls or witnessed incidents. Despite facility policy requiring immediate reporting of such injuries, staff did not report the incident to the state agency within the mandated timeframe, as confirmed by the administrator and LPN interviews.
A medication error rate of 7.69% was observed when a CMA administered incorrect doses of Polyethylene Glycol 3350 and Senna Plus to a resident with constipation, contrary to physician orders. The errors were confirmed by the CMA, resulting in the facility exceeding the acceptable medication error rate.
Staff did not consistently follow Enhanced Barrier Precautions for two residents with high-risk conditions, including not wearing required PPE during care and failing to sanitize shared equipment. One resident with a gastrostomy tube received care from a CNA who did not don a gown or sanitize a lift after use, while another resident with a sacral ulcer was cared for by a Hospice CNA who was unaware of the need for PPE due to lack of communication and missing signage. Facility staff confirmed these lapses in EBP protocol and communication.
Failure to Use EBP and Proper Hand Hygiene During Perineal Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for one sampled resident with wounds and skin breakdown. During observation of perineal care for the resident, two CNAs provided cleansing after a bowel movement, changed the brief, and replaced the soiled draw sheet while wearing gloves but not gowns, even though the resident had wound-related conditions that met criteria for Enhanced Barrier Precautions (EBP). One CNA was also observed leaving the resident’s room wearing soiled gloves while carrying two bags containing soiled linen and a soiled brief, then walking down the hallway to dispose of the items before removing the gloves and performing hand hygiene. The resident had diagnoses including pressure ulcer of the left heel, pressure-induced deep tissue damage of the sacral region, type 2 diabetes mellitus with hyperglycemia, diabetic chronic kidney disease, chronic kidney disease stage 3b, and need for assistance with personal care. The resident’s MDS showed a BIMS score of 13, indicating little to no cognitive impairment, and the resident required partial to moderate assistance with ADLs. The care plan identified skin breakdown related to a surgical wound to the left leg, a left heel pressure ulcer, and a pressure ulcer in the perineal/buttocks area. The DON confirmed that the resident had wound care orders for the heels and should have been placed on EBP, but this was not implemented. The DON also confirmed staff should have worn gown protection during perineal care. Facility policy stated that EBP requires gowns and gloves during high-contact activities such as providing hygiene and changing briefs or linens, and the hand hygiene policy stated that gloves do not replace hand washing and that hand hygiene is required immediately after glove removal.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) received their required annual performance evaluations. Review of personnel files for these CNAs revealed that none had an annual performance evaluation completed since their date of hire. The facility's policy requires ongoing performance management and annual evaluations for all associates, with managers held accountable for ensuring these are completed. Despite this, there was no documentation of completed evaluations for the CNAs reviewed. Interviews with facility staff revealed a lack of awareness and follow-through regarding the requirement for annual performance reviews. The Assistant Director of Nursing (ADON) was not aware that staff needed annual performance reviews. The Human Resources Director stated that she provides department managers with a monthly list of employees due for evaluation but rarely receives completed reviews in return, confirming the absence of evaluations for the CNAs in question. Both the Director of Nursing (DON) and the Administrator acknowledged that the regulation requires annual performance evaluations for CNAs.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin for one resident, which was required by their abuse prohibition policy. The resident, who had severe cognitive impairment due to Alzheimer's and dementia, was found to have a left wrist fracture with no documented falls or witnessed incidents. Nursing notes indicated an acute radial fracture, and an X-ray confirmed a hairline fracture of the distal radius. Despite a full investigation into the cause of the fracture, the etiology could not be determined, and there were no witnesses to the injury. Staff interviews revealed that the LPN was notified of the resident's swollen wrist and reported the incident to the DON after learning of the fracture. The administrator, who served as the abuse coordinator, acknowledged that the incident should have been reported as an injury of unknown origin within the mandated timeframe but confirmed that no report was made to the state agency. The facility's failure to report the injury as required decreased their ability to protect the resident and ensure a safe environment during the investigation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in a calculated error rate of 7.69 percent. During medication administration observations, three LPNs and two Certified Medication Aides (CMAs) were monitored across three halls, with a total of 25 medication opportunities reviewed. Two medication errors were directly observed involving one CMA administering medications to a resident. Specifically, the CMA administered only half the prescribed dose of Polyethylene Glycol 3350 and only one tablet of Senna Plus, despite physician orders for a full capful of Polyethylene Glycol 3350 and two tablets of Senna Plus every 12 hours. The errors were confirmed by the CMA during a subsequent interview. The resident involved had physician orders for these medications to address constipation.
Failure to Adhere to Enhanced Barrier Precautions and Equipment Sanitization
Penalty
Summary
Staff failed to adhere to Enhanced Barrier Precautions (EBP) guidelines for two residents with high-risk conditions. For one resident with a history of cerebral vascular accident, diabetes, COPD, and a gastrostomy tube, a Certified Nursing Assistant (CNA) entered the room multiple times to provide care and use a sit-to-stand lift without donning a gown, as required by EBP policy. The CNA also failed to sanitize the lift after use. Interviews revealed confusion among staff regarding the necessity of wearing gowns for residents with gastrostomy tubes, even when not in use, and the expectation to sanitize equipment after each use. For another resident with late-onset Alzheimer's disease and a stage IV sacral pressure ulcer, there was no Personal Protective Equipment (PPE) cart outside the room during one observation, and a Hospice CNA provided direct care, including bathing and linen changes, without donning PPE as indicated by EBP signage. The Hospice CNA was unaware that the resident was on EBP, citing a lack of communication from the facility. The PPE cart was later replaced, but it was confirmed that it had been missing on previous days. Interviews with facility staff, including an LPN and the Infection Control Preventionist (ICP), confirmed that both residents were on EBP due to their medical conditions and that staff were expected to use gowns and gloves during care and to sanitize equipment after use. The ICP acknowledged the lapses in communication and adherence to EBP protocols, including the failure to inform Hospice staff and ensure PPE availability.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cartersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cartersville Center For Nursing And Healing | 0.8 mi | ★★★★★ | 5 | 0 |
| Cartersville Crossing Of Journey Llc | 1.4 mi | ★★★★★ | 7 | 0 |
| Chulio Hills Health And Rehab | 14.6 mi | ★★★★★ | 12 | 0 |
| Ross Memorial Health Care Ctr | 14.8 mi | ★★★★★ | 0 | 0 |
| Woodstock Center For Nursing And Healing Llc | 17.1 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.