Cycle 1
Health 2025-03-20 · Fire 2025-03-20
16 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Carrollton, GA
BHM Carrollton OpCo Inc
1-star overall rating with 2-star inspections with $3,728 in total fines with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2327 North Highway 27, Carrollton, GA
(770) 834-4404
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
159
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cypress Skilled Nursing
Operator or chain grouping
Approved since
1989-05-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 3 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
0.19
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
0.86
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
1.40
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.54
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
1.22
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
1.53
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,735
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.20
Baseline 20.06% · Performance 19.95% · Measure score 3.20 · Achievement 3.20 · Improvement 0
Healthcare-associated infections
3
Baseline 8.42% · Performance 7.22% · Measure score 3 · Achievement 2.06 · Improvement 3
Total nurse turnover
0
Baseline 61.63% · Performance 67.89% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.47 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 11.54% · Lower 95% interval 7.3% |
| Discharge to community | 42.15% |
50.57%
8.4 pts worse
|
Worse than the National Rate · Eligible stays 90 · Observed rate 33.33% · Lower 95% interval 33.46% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 92.41% |
95.27%
2.9 pts worse
|
Numerator 73 · Denominator 79 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 79 |
| Discharge self-care score | 57.45% |
53.69%
3.8 pts better
|
Numerator 27 · Denominator 47 |
| Discharge mobility score | 46.81% |
50.94%
4.1 pts worse
|
Numerator 22 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 3.8% |
2.29%
1.5 pts worse
|
Numerator 3 · Denominator 79 · Adjusted rate 3.62% |
| Healthcare-associated infections requiring hospitalization | 7.22% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 7.94% · Lower 95% interval 4.44% |
| Staff COVID-19 vaccination coverage | 5.05% |
8.2%
3.1 pts worse
|
Numerator 5 · Denominator 99 |
| Staff flu vaccination coverage | 14.95% |
42%
27.1 pts worse
|
Numerator 16 · Denominator 107 |
| Discharge function score | 55.32% |
56.45%
1.1 pts worse
|
Numerator 26 · Denominator 47 |
| Transfer of health information to provider | 81.25% |
95.95%
14.7 pts worse
|
Numerator 26 · Denominator 32 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.13% |
25.2%
2.9 pts better
|
Numerator 9 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.2
0.1 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
91.2%
4 pts better
|
93.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 94.8% · Q3 92.6% · Q4 97.9% · 4Q avg 95.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
95.0%
1.1 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.2%
0.2 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.2% · Q3 2.8% · Q4 2.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 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 who lose too much weight | 4.1% |
5.9%
1.8 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 6.0% · Q4 5.3% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
20.7%
5.2 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 25.0% · Q3 24.7% · Q4 22.8% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.2% |
21.4%
1.8 pts worse
|
16.7%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 21.9% · Q3 23.2% · Q4 20.0% · 4Q avg 23.2% · 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 | 29.9% |
17.9%
12 pts worse
|
16.3%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 27.5% · Q3 33.1% · Q4 37.4% · 4Q avg 29.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.9% |
16.2%
5.7 pts worse
|
14.9%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 22.8% · Q3 21.2% · Q4 21.6% · 4Q avg 21.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
1.1%
1.6 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 3.6% · Q4 2.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.5%
0.4 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.1% · Q3 2.8% · Q4 1.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
16.1%
9.6 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 42.7% · Q3 26.0% · Q4 13.3% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.2%
About the same
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.5% · Q3 7.4% · Q4 10.6% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.3% |
80.4%
6.1 pts worse
|
81.7%
7.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.0% · Q2 69.5% · Q3 73.0% · Q4 80.6% · 4Q avg 74.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.4% |
12.2%
11.2 pts worse
|
12.0%
11.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 23.2% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.6% |
78.2%
14.6 pts worse
|
79.7%
16.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
24.2%
3.4 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 21.7% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-03-31 · Fire 2022-03-31
14 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-03-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-03-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-09
E · Potential for more than minimal harm
2023-12-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-07
K224 · Egress Deficiencies
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-07
D · Potential for more than minimal harm
2023-12-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-07
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-09
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 2025-10-24
G · Actual harm
2025-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-03-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-03-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-20
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 2025-06-13
D · Potential for more than minimal harm
2025-03-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-20
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 2025-06-13
D · Potential for more than minimal harm
2025-03-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-20
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 2025-06-13
D · Potential for more than minimal harm
2025-03-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-20
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-20
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-06-13
E · Potential for more than minimal harm
2023-12-07
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 2024-01-21
D · Potential for more than minimal harm
2023-12-07
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-21
G · Actual harm
2022-03-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-20
G · Actual harm
2022-03-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-20
F · Potential for more than minimal harm
2022-03-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-05-20
F · Potential for more than minimal harm
2022-03-31
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-05-20
E · Potential for more than minimal harm
2022-03-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-31
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-31
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 2022-05-20
D · Potential for more than minimal harm
2022-03-31
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-31
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-31
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 2022-05-20
D · Potential for more than minimal harm
2022-03-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-05-20
Penalties and ownership
What sits behind the stars
$3,728
2023-12-07
Fine
Fine · fine $3,728
Fine
Ownership
Cypress Operating LLC
5% Or Greater Indirect Ownership Interest · Organization
Cypress Skilled Nursing LLC
5% Or Greater Direct Ownership Interest · Organization
Carter, Janice
Operational/Managerial Control · Individual
Ovits, Isaac
Operational/Managerial Control · Individual
Ovits, Isaac
Corporate Officer · Individual
Patterson, Dianne
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Carrollton Manor, Incorporated
Carrollton, GA
1-star overall rating with 2-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
PruittHealth - Carrollton
Carrollton, GA
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
BHM Pine Knoll OpCo Inc
Carrollton, GA
3-star overall rating with 4-star inspections with $5,244 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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