Cycle 1
Health 2025-02-06 · Fire 2025-02-06
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Marietta, GA
Autumn Breeze Health And Rehab
1-star overall rating with 1-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1480 Sandtown Road Sw, Marietta, GA
(770) 422-1755
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
109
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
C. Ross Management
Operator or chain grouping
Approved since
1995-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 1 staffing / 2 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
0.28
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
2.74
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,002
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.33% · Performance 22.01% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.16
Baseline 8.74% · Performance 8.12% · Measure score 1.16 · Achievement 0 · Improvement 1.16
Total nurse turnover
6.07
Baseline 39.66% · Performance 38.89% · Measure score 6.07 · Achievement 6.07 · Improvement 0.02
Adjusted total nurse staffing
0.11
Baseline 2.93 hours · Performance 3.10 hours · Measure score 0.11 · Achievement 0 · Improvement 0.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 17.54% |
10.72%
6.8 pts worse
|
Worse than the National Rate · Eligible stays 103 · Observed rate 29.13% · Lower 95% interval 13.11% |
| Discharge to community | 61% |
50.57%
10.4 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 51.28% · Lower 95% interval 45.99% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 30.77% |
95.27%
64.5 pts worse
|
Numerator 12 · Denominator 39 |
| Falls with major injury | 5.13% |
0.77%
4.4 pts worse
|
Numerator 2 · Denominator 39 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 5.13% |
2.29%
2.8 pts worse
|
Numerator 2 · Denominator 39 · Adjusted rate 3.1% |
| Healthcare-associated infections requiring hospitalization | 8.12% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 11.76% · Lower 95% interval 4.89% |
| Staff COVID-19 vaccination coverage | 1.71% |
8.2%
6.5 pts worse
|
Numerator 2 · Denominator 117 |
| Staff flu vaccination coverage | 1.67% |
42%
40.3 pts worse
|
Numerator 2 · Denominator 120 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
91.2%
6.7 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 98.9% · Q3 97.4% · Q4 97.5% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.0% |
95.0%
8 pts worse
|
95.5%
8.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.2%
0.4 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 6.4% · Q4 3.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.9% |
9.6%
17.3 pts worse
|
11.4%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 21.8% · Q3 36.6% · Q4 26.0% · 4Q avg 26.9% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.9%
0.5 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 5.2% · Q3 5.6% · Q4 2.9% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.0% |
20.7%
1.3 pts worse
|
19.6%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 21.2% · Q3 24.3% · Q4 22.4% · 4Q avg 22.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 40.9% |
21.4%
19.5 pts worse
|
16.7%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 40.4% · Q3 43.9% · Q4 35.7% · 4Q avg 40.9% · 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 | 36.1% |
17.9%
18.2 pts worse
|
16.3%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.3% · Q2 25.2% · Q3 13.3% · Q4 16.4% · 4Q avg 36.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
16.2%
3.5 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.7% · Q2 12.7% · Q3 11.9% · Q4 11.8% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.1%
0.2 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.9% · Q3 0.0% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.5%
1.5 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
16.1%
8.3 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 26.7% · Q3 28.7% · Q4 17.1% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
6.2%
3.4 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.1% · Q3 1.1% · Q4 4.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
80.4%
16.7 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 96.0% · Q3 100.0% · Q4 96.2% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
12.2%
4.9 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 7.4% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
2.2%
1.4 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 16.7% |
78.2%
61.5 pts worse
|
79.7%
63 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 16.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
24.2%
0.6 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 22.2% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-14 · Fire 2022-11-14
9 health deficiencies
Top issue: Administration (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-04-29 · Fire 2021-04-29
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-09
D · Potential for more than minimal harm
2025-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-09
D · Potential for more than minimal harm
2025-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-09
D · Potential for more than minimal harm
2025-02-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-09
D · Potential for more than minimal harm
2025-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-09
E · Potential for more than minimal harm
2022-11-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-10
E · Potential for more than minimal harm
2021-04-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-06-13
D · Potential for more than minimal harm
2021-04-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Not marked corrected
D · Potential for more than minimal harm
2021-04-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-06-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-03-09
K · Immediate jeopardy
2022-11-14
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 2023-01-10
K · Immediate jeopardy
2022-11-14
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 2023-01-10
K · Immediate jeopardy
2022-11-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-10
K · Immediate jeopardy
2022-11-14
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-01-10
K · Immediate jeopardy
2022-11-14
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-14
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-11-14
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-01-10
E · Potential for more than minimal harm
2021-04-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-06-13
Penalties and ownership
What sits behind the stars
Ownership
Winget, Michael
5% Or Greater Direct Ownership Interest · Individual
Janes, Carrol
Operational/Managerial Control · Individual
Winget, Michael
Operational/Managerial Control · Individual
Winget, Michael
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Pruitthealth - Marietta
Marietta, GA
2-star overall rating with 2-star inspections with $13,520 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
A.g. Rhodes Home, Inc - Cobb
Marietta, GA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Roselane Health Center By Harborview
Marietta, GA
1-star overall rating with 2-star inspections with $86,242 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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