Above average — CMS composite of the measures below.
The next survey window likely opens 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 Starr Regional Health & Rehabilitation during CMS and state inspections, most recent first.
Unsanitary oral care storage, missed EBP PPE, and improper medication handling: Two residents’ toothbrushes were observed unlabeled, uncovered, and touching on a shared shelf. An LPN did not wear a gown during wound care for a resident on EBP with chronic wounds. An RN also picked up and administered two tablets that had fallen onto the med cart during prep instead of discarding them.
The facility failed to report Payroll-Based Journal (PBJ) data for the fourth quarter of 2023, covering the period from July 1 to September 30. The Administrator confirmed that the PBJ data had not been submitted by the required deadline.
The facility failed to accurately complete an MDS assessment for a resident with Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Peripheral Vascular Disease. The Quarterly MDS assessment inaccurately indicated the presence of a feeding tube, which was confirmed to be incorrect through observation and staff interviews.
The facility failed to submit a Level I PASARR for a resident admitted with diagnoses including Psychosis, Anxiety Disorder, Adult Failure to Thrive, and Dementia. The omission was confirmed by the DON and BDC, who mistakenly believed the resident did not require a PASARR.
The facility failed to update a PASARR after a new mental health diagnosis of Anxiety was added for a resident. Despite the resident's readmission with Anxiety and confirmation through a significant change MDS assessment, the PASARR was not revised, as confirmed by the Business Development Coordinator.
The facility failed to post daily staffing information as required by their policy. During an observation, it was noted that the daily staff posting was outdated by two days. The Administrator confirmed that the daily staffing information had not been updated and posted as required.
A facility failed to ensure proper infection control practices during medication administration for a resident with Chronic Respiratory Failure, Congestive Heart Failure, and Dementia. An RN dropped a Baclofen pill on an unclean cart, picked it up with an ungloved hand, and administered it. The RN also broke a Nuedexta tablet with an ungloved hand. The DON confirmed that proper procedures were not followed.
Unsanitary oral care storage, missed EBP PPE, and improper medication handling
Penalty
Summary
The facility failed to maintain infection control by storing oral hygiene equipment in an unsanitary manner for two residents. Residents #31 and #52 shared a room with a metal shelf above the sink, where two toothbrushes were observed lying together, touching, unlabeled, and uncovered on multiple observations. Resident #52 had diagnoses including Alzheimer's Disease, Chronic Pain, and Osteoarthritis, was assessed with severe cognitive impairment, and was dependent on staff assistance for oral hygiene. Resident #31 had diagnoses including Dementia, Heart Failure, and Crohn's Disease, had broken teeth, and was documented as needing assistance with mouth care daily and as needed. The facility also failed to use proper PPE for Enhanced Barrier Precautions for Resident #51 and failed to administer medications in a sanitary manner for Resident #6. Resident #51 had diagnoses including Alzheimer's Disease, Chronic Pain, and Osteoarthritis, had severe impairment for cognitive skills for daily decision making, and had an order for Enhanced Barrier Precautions for chronic wounds; during wound care, an LPN did not don a gown as required. Resident #6 had diagnoses including Heart Failure, Lung Disease, and Legal Blindness; during medication preparation, an RN allowed an escitalopram tablet to fall into an open drawer and a potassium chloride tablet to fall onto the medication cart, then picked up both tablets and administered them to the resident. The RN confirmed the tablets should have been discarded, and the DON confirmed the medication administration did not follow infection control practices.
Failure to Submit PBJ Data for Q4 2023
Penalty
Summary
The facility failed to report Payroll-Based Journal (PBJ) data for the fourth quarter of 2023, covering the period from July 1 to September 30. This deficiency was identified through a review of the facility's policy on reporting direct-care staffing information, which mandates that such data be submitted electronically to CMS. The review of the Quarterly PBJ for the specified period showed that the facility did not submit the required data. During an interview on February 6, 2024, the Administrator confirmed that the PBJ data had not been submitted by the required deadline.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident. Resident #46, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Peripheral Vascular Disease, had an inaccurate entry in the Quarterly MDS assessment indicating the presence of a feeding tube. An observation confirmed that the resident did not have a feeding tube in place. Interviews with a Registered Nurse and the Director of Nursing, along with MDS Coordinators, confirmed that the MDS completed on 1/15/2024 was not accurate, as the resident had never had a feeding tube to the knowledge of the staff.
Failure to Submit Level I PASARR for Resident
Penalty
Summary
The facility failed to ensure a Level I PASARR (Preadmission Screening and Resident Review) was submitted for one resident. The facility's policy mandates that all residents admitted to a Medicaid-funded nursing facility be screened for serious mental illness, intellectual disability, or developmental disability to ensure the nursing facility is the most appropriate place for the resident. Resident #25, who was admitted with diagnoses including Psychosis, Anxiety Disorder, Adult Failure to Thrive, and Dementia, did not have a Level I PASARR included in the facility's records. This omission was confirmed during an interview with the Director of Nursing and the Business Development Coordinator, who mistakenly believed the resident was 'grandfathered in' and did not require a PASARR. The deficiency was identified through a review of the facility's policy, medical records, and interviews with staff. The Comprehensive Care Plan for Resident #25 indicated impaired cognitive function related to Dementia with psychosis and Adult Failure to Thrive. Despite these significant mental health diagnoses, the facility failed to submit the required Level I PASARR to the designated agency, as confirmed by the Business Development Coordinator. This oversight indicates a lapse in adherence to federally mandated screening processes designed to ensure appropriate placement and services for residents with serious mental health conditions.
Failure to Update PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to update a Pre-Admission Screening and Resident Review (PASARR) after a new mental health diagnosis of Anxiety was added for a resident. The resident was admitted and readmitted to the facility with diagnoses including Atrial Fibrillation, Anxiety, and Dementia. A PASARR dated March 12, 2021, indicated no known or suspected mental health diagnosis. However, a Physician Admission/Readmit Order dated November 27, 2023, showed Anxiety as a new diagnosis. A significant change Minimum Data Set (MDS) assessment confirmed the active diagnosis of Anxiety and the use of anti-anxiety medications. Despite these updates, the PASARR was not revised to reflect the new mental health diagnosis, as confirmed by the Business Development Coordinator during an interview on February 6, 2024.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post daily staffing information as required by their policy. The policy, dated December 2023, mandates that staffing information be posted and updated at the beginning of each shift by a designated staff member. However, during an observation on February 4, 2024, at 10:15 AM, it was noted that the daily staff posting was dated February 2, 2024. In an interview conducted on the same day at 11:32 AM, the Administrator confirmed that the daily staffing information had not been updated and posted as required, contrary to his expectations.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for one resident. During an observation, a Registered Nurse (RN) prepared medications for a resident and dropped a Baclofen pill on the unclean medication cart. The RN picked up the medication with an ungloved hand and placed it into a medication cup. Additionally, the RN obtained a Nuedexta tablet with an ungloved hand, broke the tablet, and placed it into the cup before administering the medications to the resident. The resident involved had a medical history that included Chronic Respiratory Failure, Congestive Heart Failure, and Dementia. The RN acknowledged that the dropped Baclofen pill should have been discarded and another pill obtained. The RN also admitted that hands should have been washed and gloves donned prior to breaking the Nuedexta tablet. The Director of Nursing confirmed that it was her expectation for medications dropped to be discarded and for proper hand hygiene and glove use to be followed during medication administration.
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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 Etowah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Etowah Health And Rehabilitation | 2.6 mi | ★★★★★ | 10 | 0 |
| Life Care Center Of Athens | 7.2 mi | ★★★★★ | 12 | 1 |
| Nhc Healthcare, Athens | 7.6 mi | ★★★★★ | 0 | 0 |
| Monroe Health And Rehabilitation Center | 12.6 mi | ★★★★★ | 18 | 0 |
| Waters Of Sweetwater A Rehabilitation & Nursing | 15.1 mi | ★★★★★ | 0 | 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.