Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Winthrop Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to Timely Report Allegations of Abuse or Serious Injury: The facility failed to timely report fall-related allegations involving two residents as required by policy. One resident had Alzheimer's disease, severe cognitive impairment, and a left femur fracture after a fall with major injury; the DON stated the incident was not reported to the SSA, and the Administrator believed it was not regulatory to report it.
Failure to thoroughly investigate a fall with major injury: A resident with Alzheimer's disease and significant cognitive impairment was found on the floor next to the bed with severe left hip pain and was sent to the ED for further treatment after sustaining a fracture-related injury. The DON stated there was no investigation beyond morning discussions and QAPI, and the Administrator said the resident was later placed on hospice after returning from the hospital.
Medication Administration Errors Exceeded Allowed Rate: Surveyors observed a CMA give medications late to three residents, resulting in 9 errors out of 33 opportunities and a 27.27% error rate. Medications scheduled for 8:00 a.m. were administered well outside the facility’s 60-minute window, and the DON, ADON, and Regional Nurse confirmed the late administration; the CMA stated he could not start the med pass on time because the internet was down.
The facility failed to document controlled medication shift counts properly, missing nurse signatures on narcotic shift count sheets for two medication carts over several months. Interviews with nursing staff and the DON confirmed the deficiency, attributing it to nurses being in a hurry. This oversight could lead to missing medications, as the accountability process was not followed.
The facility failed to properly store opened food items, affecting 67 residents receiving an oral diet. Observations showed several food items in the walk-in refrigerator, freezer, and dry storage area were not labeled, dated, or securely wrapped. Additionally, two bags of shredded hash browns were found on the floor of the freezer. The CDM confirmed these deficiencies, acknowledging that staff were expected to follow proper storage protocols.
A facility failed to implement Enhanced Barrier Precautions (EBP) during wound care and high-contact ADL for a resident with a stage three pressure ulcer. The Infection Preventionist/Wound Care Nurse and a CNA did not wear gowns as required, despite being aware of the guidelines and the availability of PPE. The Director of Nursing confirmed the necessity of following EBP to prevent infection transmission.
Failure to Timely Report Allegations of Abuse or Serious Injury
Penalty
Summary
The facility failed to timely report allegations of abuse/serious injury related to falls for two sampled residents, including R71 and R49. The facility policy titled, Reporting and Investigating Abuse, required allegations of abuse or serious bodily injury to be reported immediately but no later than 2 hours, and allegations not involving abuse or serious bodily injury to be reported immediately but no later than 24 hours. For R71, the EMR showed diagnoses including Alzheimer's disease with late onset and a displaced intertrochanteric fracture of the left femur, and MDS assessments documented moderate to severe cognitive impairment with assistance needed for ADLs. The record showed R71 was transferred to the hospital and later returned to the facility, and a Facility Incident Report documented witnessed falls with major injury. During interviews, the DON stated R71 fell, was sent to the hospital, and when fracture results were received, the fall with major injury was not reported to the State Survey Agency. The DON stated she intended to report it but forgot because she was handling several other reportable incidents, and the Administrator stated he believed the DON forgot to report it and said it was not regulatory to report it.
Failure to Thoroughly Investigate a Fall With Major Injury
Penalty
Summary
The facility failed to conduct a thorough investigation of a fall that resulted in a major injury for one resident, R71. R71 was admitted with diagnoses of Alzheimer's disease with late onset and a displaced intertrochanteric fracture of the left femur, subsequent encounter for closed fracture with routine healing. The discharge with anticipation to return MDS documented a BIMS score of eight, and the entry tracking MDS later documented a BIMS score of three, indicating severe cognitive impairment and need for assistance with ADLs. The EMR documented that R71 was transferred to the hospital on 8/29/2025 and returned to the facility on 9/2/2025. Nurse's notes stated that at approximately 5:30 a.m. on 8/29/2025, R71 was found on the floor next to the bed by a CNA, the nurse was notified, vital signs and an assessment were completed, and the resident had 10/10 left hip pain. EMS was called to transport the resident to the emergency department for further treatment. During interviews, the DON stated there was no investigation done related to R71's fall outside of morning discussions and QAPI, and the Administrator stated falls were discussed in morning rounds and individualized investigations were done, but for R71 specifically, she was away and when she returned to the facility she was put on hospice.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained at 5% or less. Surveyors observed Certified Medication Aide (CMA) BB administering medications late to three residents, resulting in 9 errors out of 33 opportunities and a total error rate of 27.27%. The facility policy titled Medication Administration-General stated that medications are to be administered within 60 minutes before or after the scheduled time unless otherwise specified by the prescriber. For one resident, duloxetine 60 mg, finasteride 5 mg, and gabapentin 100 mg scheduled for 8:00 a.m. were given at 10:39 a.m. For a second resident, metoprolol tartrate 50 mg, potassium chloride 10 mEq, and Eliquis 2.5 mg scheduled for 8:00 a.m. were given at 10:51 a.m. For a third resident, gabapentin 400 mg and acetaminophen 325 mg, quantity x2, scheduled for 8:00 a.m. were given at 11:04 a.m. The DON stated the internet was down on the morning of 9/15/2025 and that the medications appeared in red on the MAR when late. The DON, ADON, and Regional Nurse later confirmed that CMA BB was late giving medications to the three residents, and CMA BB stated he was unable to start the medication pass until around 8:00 a.m. or 8:30 a.m. because the internet was down.
Deficient Documentation of Controlled Medication Counts
Penalty
Summary
The facility failed to ensure proper documentation of controlled medication shift counts, as required by their policy titled 'Pharmacy Services, Controlled Substance Medication Accountability.' This policy mandates that controlled medications be tracked from receipt through administration and that a physical inventory be conducted by two licensed nurses at each shift change. The inventory is to be documented on a 'Controlled Drug Sheet Audit Report,' with both nurses confirming and signing off on the count. However, the report found that nurse signatures were missing from the narcotic shift count sheets on two nurse medication carts over several months. Specifically, the narcotic shift count sheet for Unit 1 was missing multiple nurse signatures for the months of February, March, April, May, and June 2024. The missing signatures included both on-duty and off-duty nurses across various shifts, indicating a lack of compliance with the facility's policy. Similarly, Unit 2's narcotic shift count sheet was missing signatures for two shifts in June 2024. Interviews with nursing staff, including an LPN and an RN, confirmed the absence of signatures and acknowledged that nurses should sign the count sheet at the beginning and end of their shifts. The Director of Nursing (DON) confirmed the deficiency, attributing the missing signatures to nurses being in a hurry and neglecting to sign the document. This oversight in documentation could potentially lead to missing medications, as the controlled medication accountability process was not being followed as intended. The facility's failure to adhere to its own policy for controlled substance medication accountability was evident in the repeated absence of required nurse signatures on the narcotic shift count sheets.
Improper Food Storage in Facility
Penalty
Summary
The facility failed to properly store opened food items in the walk-in refrigerator, walk-in freezer, and dry storage area, which had the potential to affect all 67 residents receiving an oral diet from the kitchen. Observations revealed several instances of non-compliance with the facility's policy on food storage. In the walk-in refrigerator, an opened five-pound bag of grated parmesan cheese was found securely wrapped but without an open date. In the walk-in freezer, a clear plastic bag containing breaded shrimp, an opened bag of hot dogs, hash brown patties, and a brown bag of French fries were all found without labels or open dates, and not securely wrapped. Similarly, in the dry storage area, an opened bag of spaghetti noodles, yellow cake mix, and penne pasta were found without open dates and not securely closed. Additionally, two bags of shredded hash browns were observed on the floor of the walk-in freezer, contrary to the facility's policy that food items should be stored off the floor and on shelves. The Certified Dietary Manager (CDM) confirmed these observations and acknowledged that the dietary staff were expected to securely wrap, label, and date opened food items before storage. The CDM also noted that the bags of shredded hash browns must have been accidentally knocked off the shelf.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that nursing staff implemented Enhanced Barrier Precautions (EBP) during wound care and high-contact Activities of Daily Living (ADL) for a resident requiring such precautions. The facility's policies outlined the need for Personal Protective Equipment (PPE), including gowns and gloves, during high-contact care activities to prevent the transmission of multidrug-resistant organisms (MDRO). However, during an observation, the Infection Preventionist/Wound Care Nurse provided wound care to a resident with a stage three pressure ulcer without wearing a gown, despite being aware of the requirement. Additionally, a Certified Nursing Assistant (CNA) assisted the same resident with incontinent care, dressing, personal hygiene, and transferring without wearing a gown, even though she acknowledged the need to do so due to the resident's condition. Both staff members confirmed their awareness of the EBP guidelines and the availability of PPE, yet failed to adhere to the protocols. The Director of Nursing also confirmed that staff should follow EBP guidelines and acknowledged that the failure to do so could lead to increased infection rates among residents.
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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 Rome
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Etowah Landing | 2.1 mi | ★★★★★ | 7 | 0 |
| Fifth Avenue Health Care | 2.9 mi | ★★★★★ | 9 | 0 |
| Evergreen Health And Rehabilitation Center | 3.5 mi | ★★★★★ | 10 | 0 |
| Magnolia Place Nursing And Rehabilitation | 5.2 mi | ★★★★★ | 0 | 0 |
| Harborview Rome | 5.2 mi | ★★★★★ | 6 | 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.