Emory University Hospital
An acute care hospital in Atlanta, Georgia 30322
1364 Clifton Road, NE, Atlanta, Georgia 30322. (404) 686-8500.
- Medicare payments cut under the HAC Reduction Program (fiscal year 2026)
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The short answer
Record last released by CMS on Oct 20, 2026.
- 4of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 1 deficiency cited in the last three years
- 661 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Aug 21, 2026: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Dec 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Dec 17, 2025: complaint inspection1 deficiency
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Staffing And Delivery Of Care
The inspectors’ words, 570 words
“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 49398 Based on a medical record review, staff interviews, and review of policy titled “Patient Care Orders,” it was determined that nursing staff failed to complete wound care as ordered for one patient (P) (P#1) of four patients (P#2, P#3, and P#4) reviewed. Findings Included: A review of P#1’s medical record revealed P#1 was admitted to the facility on 5/26/25 for deep infection associated with the driveline of a ventricular assist device (VAD-a pump that is used for patients who have reached end-stage heart failure). A review of “Other Orders,” dated 5/28/25, revealed an order for sterile VAD dressing changes to be performed daily and as needed for soiling until specified. Review of records for P#1failed to reveal that documented dressing changes were performed on 5/31/25 and 6/1/25. During an interview on 12/17/25 at 7:45 a.m. in a conference room, Registered Nurse (RN) AA stated that nursing staff must follow provider orders. For an active dressing change order, the nurse selects the order in the system and follows protocol. If a change is needed, the nurse contacts the provider to discuss it. RN AA explained that all dressing changes should be documented in the flowsheet and could not recall any instance in which it would be appropriate not to document them. A telephone interview was conducted on 12/17/25 at 10:23 a.m. with Registered Nurse (RN) CC. RN CC reported that on 5/31/25, while serving as charge nurse on the 4G Unit, she cared for P#1. RN CC stated that nursing staff are required to follow provider orders and confirmed that P#1 had daily dressing change orders. She recalled performing a dressing change for P#1on 5/31/25 but was unsure if she documented it in the medical record. RN CC also noted she was serving as charge nurse that day and, due to a high workload, may have forgotten to document the dressing change. A telephone interview was conducted on 12/17/25 at 10:33 a.m. with Registered Nurse (RN) EE. RN EE stated that he prefers to perform dressing changes in the morning. He recalled that P#1 had a daily dressing change order, which he completed and documented in the flowsheet as required; He added that there is no way he would have forgotten to document the dressing change. A telephone interview was conducted on 12/17/25 at 10:45 a.m. with Registered Nurse (RN) BB. RN BB explained that he reviews orders at the start of each shift and during shift changes to verify which are active, require renewal, or require discontinuation. He recalled that P#1 required daily dressing changes due to significant drainage, but did not recall performing a dressing change during his shift. A review of the facility’s policy titled “Patient Care Orders,” effective date 05/05/2023, revealed that the purpose of the policy was to identify parameters for ordering medical treatment for hospitalized patients. Patient Care Protocols 4. Protocols are based on diagnosis and/or presentation: c. All actions taken per protocol in response to the diagnosis/presentation must be documented as appropriate.”
All 9 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Aug 21, 2026 | Complaint inspection | No deficiencies cited |
| Aug 13, 2026 | Complaint inspection | No deficiencies cited |
| May 6, 2026 | Complaint inspection | No deficiencies cited |
| Dec 17, 2025 | Complaint inspection | 1 deficiency cited |
| Jan 30, 2025 | Complaint inspection | No deficiencies cited |
| Oct 23, 2024 | Complaint inspection | No deficiencies cited |
| Apr 17, 2024 | Complaint inspection | No deficiencies cited |
| Mar 14, 2024 | Complaint inspection | No deficiencies cited |
| Dec 11, 2023 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 4 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 3 better and 0 worse of 8; safety of care, 1 better and 1 worse of 8; readmission, 1 better and 2 worse of 11.
- Patients rate it 3 of 5 in CMS’s patient survey (556 surveys completed, Oct 1, 2024 to Sep 30, 2025): 76% rated it 9 or 10 out of 10, and 76% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), better than the national benchmark; surgical site infections after colon surgery, no different than national benchmark; surgical site infections after abdominal hysterectomy, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: worse than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.6%, heart failure 9.2%, pneumonia 13.4%, COPD 7.3%, stroke 9.2%, heart bypass surgery 2.2%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 15.4%, heart failure 20.3%, pneumonia 16.9%, COPD 20.6%, heart bypass surgery 13.6%, hip or knee replacement 5.4%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 316 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
- 32% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.94 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 4 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- It has an inpatient rehabilitation unit of 56 beds, which CMS lists apart as a rehabilitation facility.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS cut its Medicare payments by 1% for fiscal year 2026 under the Hospital-Acquired Condition Reduction Program, which does so for the quarter of hospitals that fare worst on conditions patients get in hospital.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
| Date | What | Detail |
|---|---|---|
| Medicare payment reduction (HAC Reduction Program) | Fiscal year 2026: 1% of Medicare payments |
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 2 of 5.
- 94% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- 2 owners or officers are people: Carla Cashio (managing employee (on the payroll)); Carla Cashio (runs it (operational or managerial control)).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- Of the 7 hospitals CMS lists in De Kalb County, 4 have an overall star rating from CMS: 1 rated 4 of 5, 1 rated 3 of 5, 1 rated 2 of 5, 1 rated 1 of 5.
- CMS rates this one 4 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Emory Decatur Hospital | 2 |
| Emory Hillandale Hospital | 1 |
| Decatur (Atlanta) VA Medical Center | 3 |
| Athur M Blank Hospital | Not given |
| Peachford Behavioral Health System of Atlanta | Not given |
| Georgia Regional Hospital Atlanta | Not given |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.